MSHP MedLife System Security Request Form

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Missouri State Highway Patrol
MedLife System Security Request Form

First Name:	Middle Name:	Last Name:
Email Address:	Employee Title:
Troop:	MedLife EmplID (office use only)	Phone Number:

Reason for Request

Effective Date:

Addition of new user

Insurance Representative

Self-service

Change Privileges (Insurance representative to Self-service)
Change Privileges (Self-service to Insurance representative)
Remove Security

Explanation:

For Approver Use Only

1st Approver (Employee's supervisor):	Date:
2nd Approver (Employee Benefits staff):	Date:
3rd Approver (IS security administrator):	Date:
Request completed and employee notified via email By: Date: