01/22/2014
614225.4
Information Systems - Network and Applications Access
ACCOUNT REQUEST FORM
Section 1
Lawson ID #
NOT EMPLOYED BY NAH
Employed Staff
Employed Physician
Location:
FMC
VVMC
☐______________
Start Date:
.
Locum Physician
Registry Personnel
Traveler Personnel
Physician
Physician’s Office Staff
Volunteer
Contractor / Vendor
Temporary
Med Student / Resident
Nursing Student
Other:
Instructor Name:
Instructor Phone #:
Employer’s Name:
Practice Name:
Start Date :
End Date:
.
Section 2 - Individual Information
.
Last Name
First Name
Middle Initial
Your Office Phone
Name of Supervisor / Director / Practice Manager
Supervisor’s Contact #
Business Address
City
State/Zip
Your Position / Title
Your Business Email Address
Last 4 digits of your SSN if not a NAH employee
SECURITY QUESTION: Choose one
Favorite Pet Name?
Mother’s Maiden Name?
ANSWER TO SECURITY QUESTION:
Favorite Color?
Favorite Sports Team?
City of Birth?
Security Question & Answer are used when you call the Service Center to have your password reset.
Section 3A – Signature of Applicant/Remote Access Requestor
Have you ever been terminated from employment due to a HIPAA violation?
No
Yes
I agree to protect the confidentiality and security of the protected health information ("PHI") obtained from Northern Arizona Healthcare ("NAH"). I agree to comply with applicable laws in respect to the
PHI of patients and with all existing and future NAH policies and procedures concerning the confidentiality, privacy, security, use and disclosure of PHI. I will also abide by the NAH Information Systems
security policies and certify having read IT Security Policy 32. (HSP 32)
.
Name (print)
Title
.
Date
Electronic
Signature
By entering your name and initials, you electronically acknowledge reading and understanding the above
document. Additionally, you pledge that all entries made by you are truthful and correct and that you agree that your typed signature will be the
equivalent of your hand-written signature.
Signature of Applicant/Remote Access User
Section 3B – Signature of Employer / Physician / Supervisor / Director / Instructor
I will ensure that the remote access user under my direction complies with Northern Arizona Healthcare’s privacy and security regulations and policies as specified in HSP 32.
.
Name (print)
Title
Date
Electronic
Signature
By entering your name and initials, you electronically acknowledge reading and
understanding the above document. Additionally, you pledge that all entries made by you are truthful and correct and that you agree that your typed
signature will be the equivalent of your hand-written signature.
Signature of Employer/Physician /Supervisor/Director or Instructor
01/22/2014
614225.4
Return completed form to NAH Contact Person
All Remote Access Requestors must complete, sign and return both the Remote Access Agreement and the Account Request
Form to the NAH Contact Person.
Section 4A Requested Network and Application Access
(To be filled out by NAH Contact Person)
X Network Access/Citrix Access
Email Account
VPN
Lawson
Lawson Back end Process
Teletracking – XT – Patient tracking
Ansos & Web scheduler
Teletracking RTLS – Equipment tracking
QS
ISite
SSO – Single Sign On – On Site
Patient Keeper
Dragon – Physicians
Off Site Access (Citrix)
ChartOne/ChartVault/ewebhealth – VVMC only
Cerner Domains - mark all that apply
P261 – Prod
T261 – Train
M261 – Mock
C261 –Cert
B261 – Build
Define Position or whom to copy
Back end Access – DBA and DBC’s only mark all that apply
P261 – Prod T261 - Train
M261 - Mock
C261 - Cert
B261 - Build
☐Other Applications – please add below
Section 4B Justification for Access
(To be filled out by NAH Contact Person)
Please describe why this individual needs access to PHI in the NAH Information Systems.
Section 4C Signature of NAH Contact Person
I verify the requestor requires access to PHI in the NAH Information Systems for treatment, facilitation of payment and management of healthcare operations. I will notify NAH
Service Center when I become aware the employee ceases employment as disclosed and will contact NAH Legal Department if I suspect a possible breach of PHI has occurred.
Name (print)
Title
Phone Ext.
Date
Electronic
Signature
By entering your name and initials, you electronically acknowledge reading and understanding
the above document. Additionally, you pledge that all entries made by you are truthful and correct and that you agree that your typed signature will be
the equivalent of your hand-written signature.
Signature of NAH Contact Person or NAH Director or NAH Manager
Return completed form to NAH IT Security Department.
Submit a Service Center Ticket on Portal.
Section 5 NAH IT Security Department – Remote Access Administrative Authorization
Name (print)
Title
Date
Electronic
Signature
entering your name and initials, you electronically acknowledge reading and understanding the above
document. Additionally, you pledge that all entries made by you are truthful and correct and that you agree that your typed signature will be the
equivalent of your hand-written signature.
Signature of NAH IT Security Department Representative By