ELECTRONIC SIGNATURE RESET FORM
Please follow the instructions below to have your Electronic Signature password reset. To
ensure the security and privacy of patient information, we request that you provide us with a
copy of your driver’s license to substantiate your identity.
To reset your Electronic Signature:
1. Print this document.
2. Complete the requested information in the form below.
3. Photocopy your driver’s license on top of the indicated box below.
4. Sign the request form that contains the image of your driver’s license.
5. Fax the completed form to Customer Support at: (512) 519-1416
Please note! To reset your electronic signature, Customer Support must be able to read the driver’s license
clearly; faxed copies can sometimes be too dark to read. To prevent delays in resetting your electronic
signature, you may wish to:
 Scan the form and your driver's license, and e-mail to Customer Support at [email protected]
 Take a digital photo of the form and your driver's license (using a smart phone or digital camera), and
e-mail to Customer Support at [email protected]
Copy Driver’s License
over this box
____________________________________
Requestor First and Last Name
____________________________________
Organization Name
____________________________________
Requestor Signature
____________________________________
Requestor Kinnser User Name
____________________________________
Contact Phone or E-mail
____________________________________
Date
When your Electronic Signature has been reset, you will receive a message in your Kinnser
K-mail InBox. You will be prompted to create a new Electronic Signature upon your next
Electronic Signature attempt.
Please note! If you have forgotten your Log In Password information, please contact your agency administrator
directly to have that password reset. This form is used to reset Electronic Signature password information
ONLY.
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rev: 10/30/12