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Wireless Device Action Form

*Please allow 10 business days after approval for processing

Provisioning, Procurement & Contracts


2201 Park Place Ste 102
El Segundo, CA 90245

Visit: http://support.davita.com > DaVita


Information Technology And/Or IT Procurement

Index
Page 1 - Instructions
This page will explain what you need to do with this form.
Page 2 - Order Form
This page is what you need to fill out to add, change or delete an account.
Page 3 - Approval for teammate purchase phones and abide by policy rules
This page is for teammates to agree to the policy rules and regulations as well as approve any payroll deduction for a
non-standard phone.
Page 4 - Equipment Guidelines
This page explains the standard devices and teammate purchase for non-standard devices.
Instructions
Please make sure you have completed your Cell Phone Policy Access Request (everyone), Star Learning Mobile Device Synchronization
Agreement, and Mobile Device Synchronization Request (for those who want to receive email on their device) before completing this
Wireless Device Action Form.
Instructions on how to submit these requests can be found at the following link while on a DaVita network: www.tinyurl.com/mds1001
For TECHNICAL SUPPORT or warranty exchange - call your carrier. You do not need any account information.
Warranty exchange for cell phones and PDAS need to be called into the carrier by the end user to complete their technical
troubleshooting. The carrier will send you a refurbished same-model device.
Note: Warranty is only 1 year long and does not cover physical or water damage. Otherwise, call you carrier at the number below.
Please do not go into a store, as the store will not be able to help you.
Verizon: 800-922-0204
AT&T: 800-331-0500
The defective phone MUST be returned to the carrier within 14 days of receipt of the replacement. If the defective phone is not
returned, we will be charged the full price of the replacement. Return instructions will be sent with your replacement.

Filling Out this Form


*This action form is for ALL cell phone requests, except technical support and warranty exchange.*
1)
2)
3)
4)
5)
6)

Fill out page 2 and 3.


Have your form signed by your Director.
Scan or take a clear picture of this document
Submit by http://support.davita.com -> IT Procurement -> Mobile Devices -> New/Update Mobile Device.
Attach this form by clicking on
or 'Manage Attachments' at the top of the page
Fill out remaining fields and click 'Order Now'

If you have questions, please contact The IT HelpDesk at 888 782 8737
Please allow 10 business days after request approval for processing

Wireless Device Action Form

Page 1

Wireless Device Action Form

Provisioning, Procurement & Contracts

*Please allow 10 business days after approval for processing

2201 Park Place Ste 102


El Segundo, CA 90245

Instructions:
Fill out page 2 and 3 and submit by http://support.davita.com -> DaVita IT Procurement -> Mobile Devices -> New/Update Mobile Device.
Step 1: About you
User's Name:

Teammate ID *required*

Request Date:

Submitted By:

Charges go to the cost center on file with the Teammate ID.

Title:
Office Phone:

Fax:

City

ST

SHIP TO:

Address

Zip

Address

ST

City

Zip

Request
New Service

or

Yes

Existing
DaVita Cell Number

Provider: Select Provider

Step 2: What would you like to do?


I would like to Choose an Action Item from the drop down list, click arrow at Right.
Section 2A: DaVita Service and Equipment - New and Upgrade
New Service

Upgrade
Replacement

Area Code

Choose DaVita Standard Mobile Phone Select No Cost options for New and Upgrade Eligible
Choose DaVita WiFi Hotspot / MiFi

Select No Cost options for New and Upgrade Eligible

Write in Non-Standard Device - All Non-Standard Devices are TM Purchase


For Non-Standard Devices, the TM must approve the one time payroll deduction amount via page 3. See page 4 for more info.
Data is not unlimited; please be good stuards of DaVita's resources. Data service is not ordered for basic cell phones. Data is always
ordered for all Smartphones, and requires Director's signature in section 3
Section 2B: Personal to Corporate
Current phone model

Personal cell phone number


Provider

Billing Account #

Billing Name

Billing Address

Password or PIN

Billing City

Social Security #
(If moving to AT&T)

State

Zip

Section 2C: Change to Existing Service


Comments
Add Int'l Service - Voice

Add Int'l Service - Data

Change from provider listed above to:

Cancel Cell Phone - TM must revoke Traveler's Policy in CARA

Change from Corporate Plan to Personal Plan

Cancel MiFi / Jetpack assigned to teammate in Step 1

Change Cell Phone Number

Desired Area Code

Update Teammate Information - the Teammate in Step 1 is the new assigned user of this cell phone or MiFi.
Section 3: Approval - Director approval is needed for all smartphones & MiFi devices. Manager approval is needed for basic phones
Approver

Wireless Device Action Form

Title

Signature *Required*

Page 2

Wireless Device Action Form


*Please allow 10 business days after approval for processing
DaVita Responsibilities
Team Unity will be responsible for:
Provide the Wireless Device Action form
Phone purchasing
Service set-up
Support for phones that are broken, lost or stolen.
Monthly service payments
Teammate Responsibilities
Teammates will be responsible for:
All PDA devices must have a screen lock password/PIN number configured.
Maintain equipment in good condition.
Notify DaVita within 24 hours of a lost or stolen cell phone or PDA by using DaVita Support Express
http://support.davita.com.

Approval
I agree that I will abide by DaVita's Wireless Device Policy published on the VillageWeb under Departments > Telecom and to my
responsibilities laid out above.

Your Name

Your Teammate ID

Your Title

Your Signature

Quote and Approval for Payroll Deduction


Device Description

Cost Estimate less taxes* :

I agree to have the one-time deduction from my payroll for the purchase of a new wireless device. DaVita is purchasing a mobile device
for me and, as a courtesy, DaVita will pay the monthly fees because I will be using the device for business. Upon the termination
of my employment, I will keep the device. I am responsible for all hardware purchases and maintenance. I also understand that
since DaVita will pay the monthly fees and because I am using this for work-related purposes, I am required to comply with
DaVita's policies and procedures.
*If the cost is not filled in with the correct cost, you will be contacted to approve the current cost.

Your Teammate ID

Wireless Device Action Form

Your Signature

Page 3

Equipment Guidelines - DaVita Supported Mobile Device List

DaVita Standards:

Carrier
AT&T
Verizon
Verizon
AT&T
Verizon

Device Type
Cell Phone
Cell Phone
PDA
PDA
Hotspot

Model
Pantech Breeze IV LG
Rivere III
Apple iPhone 5s 16GB
Apple iPhone 5s 16GB
LTE MiFi Hotspot / USB

Colors
Grey
Grey
Gold, Silver, Space Grey Black
Gold, Silver, Space Grey Black

Davita Standards: DaVita provides a No Cost option for Teammates for all providers for new service and upgrades that are
eligible for a discount.
DaVita Non-Standard: Any other cell phone or smartphone is available as a DaVita Non-Standard device after it passes Team
Unity testing for compatiblity with DaVita's security and compliance policies. All Non-Standard devices will be paid for by the
Teammate through Payroll Deduction. Only devices from the platforms iPhone (iOS), Windows phone are supported under
"Non-Standard" devices.

Not Supported: Android devices are not approved by the DaVita due to security concerns. These devices will not
be ordered on the DaVita corporate account and personal devices will not be allowed to access the DaVita network
via email synchronization.

Mobile Device Synchronization Agreement: All teammates who want to access DaVita email on their PDA must complete
the Star Learning course MDS1001, and the Mobile Device Synchronization Access Request. The course is located at http://
learn.davita.com/?code=MDS1001. Additional instructions can be found at www.tinyurl.com/mds1001
ITSS Support: The Helpdesk, also known as ITSS, will only fully support DaVita's Standard Devices. Support includes help
with a device issue due to email connection, email syncing, OS crash, etc. For a Non-Standard phone, ITSS will assist with email
set up only. ITSS cannot assist in any way with a Not Supported phone.

Need to contact DaVita IT Support?


Click here: http://support.davita.com
Teammate Purchase: Any non-standard device will be paid by the Teammate through Payroll Deduction, whether new service
or upgrade. For upgrades that are not eligible for a provider discount, all standard and non-standard devices are full retail price.
The cost will be paid by the Teammate through Payroll Deduction.
Payroll Deduction: The cost of a Teammate Purchase device is paid by the Teammate in one lump sum 30-90 days after the
order. The cost cannot be split into multiple payments.

All Standard and Non-Standard mobile devices are compatible with DaVita's security and compliance policies.
Any Not Supported device does not meet DaVita's security and compliance policies.
For details on pricing for TM Purchase phones, contact the Provisioning Dept at "Provisioning@davita.com".

Wireless Device Action Form

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