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For Internal Use Only:

4-Next Acute Transition Of Care

(or Search & Sort) Enrollment Form

*First Name: *Last Name (PRINTED PLEASE): ***Middle


*Partners Username (Logon): ***Date of


*Hospital: ***Partners Email Address (Required):

*Work Phone #: **Partners Beeper # (Required): Work Fax #:

( )- - ( )- -

*Indicate present position: Case Manager _______PHS Liaison _______RN ______SW ______
Resource Assistant __________ Other______________

4-Next security access requested: (C)Case manager(TOC)_____ (G)Search/Sort only_______

(I)IS support_____ (M)Manager_____ (R)Reports________

4Next Transition of Care Access Only:

***I Shadowed with an experienced 4Next user on these dates before TOC class attendance:
______ ______ ______ ______
*** My 4Next Mentor’s name is (Signature-required): _______________________________

Scheduled Class Training on this Date______________________________________

Please, Do not sign up for / attend classroom training or shadowing if requesting Search & Sort access.

I, the undersigned, hereby request access to 4Next Acute Transition of Care, and I certify that:
1) I have attended or am scheduled to attend a formal 4Next Acute TOC training class, if applicable.
2) I have shadowed or will shadow an experienced user for no less than two weeks prior to class.
3) I state that I will never allow unauthorized persons to access and use 4Next under my name.
4) I will not attempt to access any information not authorized for my use via the Partners network.
5) I understand that information contained on Partners computer files is confidential and I will not
disclose it except as required in the course of my work-related duties.
6) I understand that any information learned during the performance of my Partners work and not
commonly available to the public is confidential. Such information must be protected.

I understand that if I violate any of the provisions of this certification, I may be subject to disciplinary
action. I have read and understand this Partners Confidentiality Statement.

*Signature of Requestor:____________________________________ Date:____________________

* Required Fields. Completed enrollment forms must be faxed to 617-726-6993 ATTN: BBM

Barbara Bush Meissner, R.N.

4-Next Acute Transition of Care - Product Manager; Implementation
One Constitution Center, 2 West 201 N, Fax: 617-726-6993
Charlestown, Massachusetts 02129