"*" indicates required fields Step 1 of 19 5% Hello Everyone,We are reassessing our organization controls for security, availability, confidentiality, processing integrity, and privacy. Please see the below for reference: Security:Information and systems are protected against unauthorized access, unauthorized disclosure of information, and damage to systems that could compromise the availability, integrity, confidentiality, and privacy of information or systems and affect the entity’s ability to meet its objectives.Availability: Information and systems are available for operation and use to meet the entity’s objectives.Processing integrity: System processing is complete, valid, accurate, timely, and authorized to meet the entity’s objectives.Confidentiality: Information designated as confidential is protected to meet the entity’s objectives.Privacy: Personal information is collected, used, retained, disclosed, and disposed to meet the entity’s objectives.Please keep in mind that you will still have access to what you need to preform your job description functions. Multiple meetings have been held with each team’s managers to determine what access is needed to continue to perform your work as normal. If you believe you should have access to additional permissions or another department’s information, please submit an IT Support Case in Salesforce. Post in the Case what information it is that you need access to and why you specifically need access to it. Make sure to tag your Team Manager and Team Executive within your post.Contact InformationApplicant First and Last Name* First Last User First and Last Name* First Last Applicant Email Address* User Email Address* General Systems OverviewDoes the User access WEX Health in order to perform their job?*SelectYesNoDoes the User access COBRAPoint in order to perform their job?*SelectYesNoDoes the User access Wex Health Partner Central in order to perform their job?*SelectYesNoDoes the User access Quickbooks in order to perform their job?*SelectYesNoDoes the User need access to TPAStream to perform their job?*SelectYesNoDoes the User access Employee Navigator in order to perform their job?*SelectYesNoDoes the User access FTWilliam in order to perform their job?*SelectYesNoDoes the User need access to Thomson Reuters Checkpoint to perform their job?*SelectYesNoDoes the User access Podium in order to perform their job?*SelectYesNoDoes the User access Prodoscore in order to perform their job?*SelectYesNoDoes the User need access to WorldView to perform their job?*SelectYesNoDoes the User access Sharefile in order to perform their job?*SelectYesNoDoes the User access RingCentral in order to perform their job?*SelectYesNo General Systems Overview ContinuedDoes the User access Servers below in order to perform their job?*None of theseAAAPPSKofaxWIN-EGJ7U8T8G30 (SFTP)AADC1 (10.1.1.6)Does the User access WordPress in order to perform their job?*SelectYesNoDoes the User access Amazon Web Services (AWS) in order to perform their job?*SelectYesNoDoes the User access GoDaddy in order to perform their job?*SelectYesNoDoes the User access Mail Chimp in order to perform their job?*SelectYesNoDoes the User access BPAS CensusPRO2 in order to perform their job?*SelectYesNoDoes the User access Absent Tracker in order to perform their job?*SelectYesNoDoes the User access Lucid in order to perform their job?*SelectYesNoDoes the User access Kleopatra in order to perform their job?*SelectYesNoDoes the User access FileZilla in order to perform their job?*SelectYesNoDoes the User access Connect Wise in order to perform their job?*SelectYesNoDoes the User access RICOH to create share folders in order to perform their job?*SelectYesNo WEX Health Administrator Portal (Production) AccessDoes the User access WEX Health Administrator Portal (Production) in order to perform their job?*SelectYesNoDoes the User access the Employer tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to add and update employer accounts, including plan design and management.SelectYesNoWhich sections of the Employer tab does the User need access to in order to perform their job?*None of theseEmployer SetupPayment SetupPlan SetupEmployer ReportsConsumer SetupConsumer ManagementClaim ManagementBanking ManagementBanking SetupConsumer Data ExchangeData ManagementPortal CustomizationView Employer PortalView Employer Support SummaryDoes the User access the Consumer tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to view and manage consumer accounts, including enrolling and resetting a password.SelectYesNoWhich sections of the Consumer tab does the User need access to in order to perform their job?*None of theseConsumer SetupConsumer DocumentsClaim ManagementBanking ManagementBanking SetupPlan Activity ManagementView Consumer PortalView Customer Support SummaryDoes the User access the Claims tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to file claims efficiently from your desktop. Allows you to view and substantiate claims that have been submitted for reimbursement.SelectYesNoDoes the User access the Banking tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to process claims across multiple employers as well as print and manage checks.SelectYesNoDoes the User access the Analytics tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to access business performance metrics and data sets.SelectYesNoDoes the User access the Reporting tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to view reports.SelectYesNoWhich sections of the Reporting tab does the User need access to in order to perform their job?*None of theseBanking ReportsPlan Management ReportsConsumer NotificationsDebit Card ReportsEmployer/Consumer Data ReportsBilling ReportsFraud ReportsCustom ReportsDoes the User access the Data tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to import claims across employers.SelectYesNoWhich sections of the Data tab does the User need access to in order to perform their job?*None of theseImportsExtractsIdentity Verification & OFACConsumer Self-RegistrationConsumer Data ExchangeConsumer DocumentsIP WhitelistingDoes the User access the Setup tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to set up site defaults and settings, and manage administrator and employer users.SelectYesNoWhich sections of the Setup tab does the User need access to in order to perform their job?*None of theseDefault Custom TextPortal CustomizationEmployer DefaultsConsumer DefaultsSetupUsersDoes the User access the Communications tab within WEX Health Administrator Portal (Production) in order to perform their job?*Allows you to view employer requests, service requests and training materials.SelectYesNo Other WEX Health AccessDoes the User access the WEX Support SR Site in order to perform their job?*SelectYesNoDoes the User access WEX Health Card Central in order to perform their job?*SelectYesNoDoes the User access WEX Health CRS Reporting Site in order to perform their job?*SelectYesNoDoes the User access WEX Health Administrator Portal (Staging) in order to perform their job?*SelectYesNoDoes the User access WEX Health Employer Portal (Staging) in order to perform their job?*SelectYesNoDoes the User access WEX Health Administrator Portal (Training) in order to perform their job?*SelectYesNoDoes the User access WEX Health Employer Portal (Training) in order to perform their job?*SelectYesNo COBRAPoint Administrator Portal AccessDoes the User access COBRAPoint Administrator Portal in order to perform their job?*SelectYesNoDoes the User access the Members tab within COBRAPoint Administrator Portal in order to perform their job?*SelectYesNoWhich sections of the Members tab does the User need access to in order to perform their job?*None of theseQB - Qualified BeneficiariesSPM- Special Plan MembersNPM- New Plan MembersDoes the User access the Entities tab within COBRAPoint Administrator Portal in order to perform their job?*SelectYesNoWhich sections of the Entities tab does the User need access to in order to perform their job?*None of theseClientsClient GroupsClient DivisionsCarriersBrokersDoes the User access the Utilities tab within COBRAPoint Administrator Portal in order to perform their job?*SelectYesNoWhich sections of the Utilities tab does the User need access to in order to perform their job?*None of theseAccounting UtilitiesAdministrator UtilitiesLetter UtilitiesJob QueueDoes the User access the Reports tab within COBRAPoint Administrator Portal in order to perform their job?*SelectYesNoWhich sections of the Reports tab does the User need access to in order to perform their job?*None of theseStandard ReportsAccounting ReportsMobile ReportsClient Reporting TrackingJob QueueDoes the User access the Communications tab within COBRAPoint Administrator Portal in order to perform their job?*SelectYesNoWhich sections of the Communications tab does the User need access to in order to perform their job?*None of theseNightly FilesLetter QueueCustomer Communications DownloadsMessagesDoes the User access the Wizards tab within COBRAPoint Administrator Portal in order to perform their job?*SelectYesNoWhich sections of the Wizards tab does the User need access to in order to perform their job?*None of theseAdd a new QB WizardAdd a new SPM WizardAdd a new NPM WizardAdd a new Client WizardAdd a new Client Division WizardAdd a new Client Group WizardAdd a new Carrier WizardAdd a new Broker WizardDoes the User access the Admin Section within COBRAPoint Administrator Portal in order to perform their job?*SelectYesNo Other COBRAPoint AccessDoes the User access the COBRAPoint Support SR Site in order to perform their job?*SelectYesNo Partner Central AccessPermissions are define as:Portal User role: This role gives only basic access to Partner Central. All other security roles are optional. Invoice Access: Gives access to the Invoices tile.Mobile Report Access: Gives access to the Mobile Reports tile.Portal Administrator: Gives user the ability to add users to Partner Central and manage user security roles.Which Partner Central User access permissions does the User need access to in order to perform their job?*None of thesePortal User roleInvoice AccessMobile Report AccessPortal Administrator Quickbooks AccessDoes the User access Vendor Activity within Quickbooks in order to perform their job?*SelectYesNoDoes the User access Customer Activity within Quickbooks in order to perform their job?*SelectYesNoDoes the User access Reports within Quickbooks in order to perform their job?*SelectYesNoDoes the User access to Charts of Accounts within Quickbooks in order to perform their job?*SelectYesNo TPAStream AccessSelect User Role in TPAStream*SelectTPA AdminstratorAdmin Read-only Employee Navigator AccessDoes the User access Vendor Administrator within Employee Navigator in order to perform their job?*Can manage user and settings.SelectYesNoDoes the User access Vendor Analyst within Employee Navigator in order to perform their job?*Can view Personally Identifying Information (PII) DataSelectYesNoDoes the User access Vendor Executive within Employee Navigator in order to perform their job?*Can view reportsSelectYesNoDoes the User access Vendor Portal User within Employee Navigator in order to perform their job?*Can access basic vendor portal functions.SelectYesNo FTWilliam AccessDoes the User access 5500 Forms within FTWilliam in order to perform their job?*SelectYesNoSelect User access level for 5500 Forms Package in order to perform their job.*SelectView/EditView OnlyDoes the User access 5500 Portal within FTWilliam in order to perform their job?*SelectYesNoDoes the User access 8955-SSA Forms within FTWilliam in order to perform their job?*SelectYesNoDoes the User access ACA Forms within FTWilliam in order to perform their job?*SelectYesNoSelect User access level for ACA Forms in order to perform their job.*SelectView/EditView OnlyWhich FTWilliam User access permissions does the User need access to in order to perform their job?*None of theseDeleteAddEdit Plan IDs Worldview AccessWhich Worldview User access permissions does the User need access to in order to perform their job?*None of theseFile SearchFile AddFile EditFile DeleteDoc ViewDoc EditDoc DeleteSelect the User Role in Worldview.*SelectPortal UserAdmin User Podium AccessSelect the User Role in Podium.*SelectTeam MemberTeam LeadAdmin Prodoscore AccessSelect User Role in Prodoscore*SelectStaffManagerExecutiveAdmin Sharefile AccessStandard permissions include:Create root-level folders in "Shared Folders" Access to the File Box, a personal storage space to store files for a limited period of timeAccess the People tab in the navigation bar in order to browse and add new client users to the accountAdd users to the Shared Address Book which allow other employee users to see these contacts in the systemWhich Sharefile User access permissions does the User need access to in order to perform their job?*None of theseAccess company account permissionsAccess other users' File Boxes and Sent ItemsManage employeesDelegate Admin Privileges to other employee usersEdit other users' shared distribution groupsManage Super User GroupDoes the User need access to Company Account info within Sharefile to perform their job?*These permissions allow this user to change account branding, gives access to tools regarding account history, and configuration of SAML settings.SelectYesNoDoes the User need access to Billing within Sharefile to perform their job?*These permissions allow this user to change account payment methods, alter account plan type, view billing information, or cancel the account.SelectYesNoDoes the User need access to Connectors within Sharefile to perform their job?These permissions allow this user to create and manage access to other file repository services.SelectYesNoDoes the User need access to Advance Preferences within Sharefile to perform their job?*These permissions allow this user to set up the automation of folder directory creation and file upload portals.SelectYesNo RingCentral AccessSelect User Role in Ring Central*SelectStandardManagerSuper Admin Server AccessDoes the User need access to HEW (HIPAA Eligibility Wrapper) to perform their job?*SelectYesNoDoes the User access AURORA in order to perform their job?*SelectYesNoDoes the User access Kofax Express in order to perform their job?*SelectYesNoDoes the User access Cerberus in order to perform their job?*SelectYesNo Submission Summary{all_fields}CommentsThis field is for validation purposes and should be left unchanged. 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