Remote Access Application Request
Required Access Demographic Information:
Note: Field(s) with * are required.
Practice Name*
Office Phone*
Fax*
Practice Address:*
Office Contact*
Extension
Prefer Time to Call*
Affiliate Office*
Yes No
Primary Facility:*
Kennestone Cobb Paulding Douglas Windy Hill
REMOTE ACCESS USERS PLEASE NOTE
This Remote Access Application Request is for WellStar associates and affiliated physician and practice employees who need to access WellStar resources (the Physician Portal, NextGen EMR, etc.) from outside WellStar facilities.

Please fill out this form in its entirety and direct questions to the IT Service Desk at (770) 956 - 6000.
First Name* Last Name* WS Emp # or
GA Lic #
User Type
Email Address* New Portal ID
(mirrored after)

To check the existence of previously created account, enter your email address and mouse over the e-CHECK button. Creating duplicates will cause serious delay.