User Access Request Form
Requesting or Updating Access to CarePartners Connect

CarePartners Connect allows you to control what level of access each user will have to the different features of the site. For example, there may be an employee at your program who is only responsible for marketing - in that case, you might choose to grant this user Growth Tools and Program reporting only and not access to Data Change functionality or sensitive subscriber information.

  • Please complete the form below.
  • Within 2 business days, Lifeline will verify your program information and set up access for each user you have requested.
  • The local CarePartners Connect Administrator identified on your enrollment form (typically the Lifeline Program Manager) will receive by e-mail the user name and password information to distribute.
  • If you need assistance completing this form, contact Program Services at 1-800-852-5433.
 Step 1 - Tell us about your Lifeline Program organization
   * Required fields
   *Lifeline Program Name:
   *Lifeline Program City:
   *Lifeline Program State:   *Lifeline Program Zip Code:
   *Response Center Location:

 Step 2 - Tell us who the CarePartners Connect Administrator is at your organization
   We may contact this person if we have questions about program codes, users or user access.
   * Required fields
   *CPC Administrator Name:  
   *CPC Administrator Phone: - - x
   *CPC Administrator Email:

 Step 3 - List the program codes for this Lifeline Program
   * Required field
   *Program Codes:

 Step 4 - List users and assign security level
   Assign a security level to each user. Select access to ALL reports, a group of reports or individual reports.
   Please note, selecting an ALL grouping will include all future reports added to the system.
   * Required fields

User #1
* User's First Name:   * User's Last Name:  

  User's Email Address:  

  Indicate program codes the user has access to if different than Step 3

*TelConnect Access:
Yes No Would you like this user to have access to TelConnect, Lifeline's automated unit assignment, swap, and deactivation telecommunication tool?

*Web Site Access:
Growth Tools Message Boards LifeWare Information (Check if your Program uses LifeWare)
Data Change (Update Subscriber information)
ALL Reports
ALL Program Level Reports
  Subscriber Lists
  Installation List
  Deactivation List
  Check-In Call
  Case Summary
  Data Change Summary
ALL Subscriber Level Reports
  Care Plan Agreement
  Case History
  Data Change Details
  ALL Organization Reports
    Program Performance
    Program Activity
Referrers:   View Only   View/Edit


Upon submission of this form,
you will be able to print a copy for your reference.

Philips Lifeline

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