Microsoft word - web use auth form - 05122009.doc

Authorization Agreement for Web Use
I (we) hereby request authorization from Central Health MSO, Inc. to use the Web Base system for the following IPAs: ___ Physicians’ Healthways IPA “PHW” ___ Advantage Care IPA “AIPA” Only Check the IPA(s) that you are contracted with.
I (we) hereby agree to employ reasonable security procedures to ensure technical and physical safeguards to protect the privacy, security, integrity and confidentiality of data electronically exchanged. I (we) hereby agree that the information provided is accurate, reliable, and complete with appropriate ICD-9 and CPT coding. I (we) hereby agree to adhere to the HIPAA policies and procedures regarding patient privacy and the security of patient information, as well as all applicable laws regarding the privacy and security of the patient information. I have read the above agreement and agree to comply with its terms as a condition of access to the Web. Primary Provider / Office Name: ___________________________________ *Telephone #: _______________________________________ *E-mail Address: _____________________________________ * A Valid E-mail and Telephone are Required to use web application Please supply Central Health MSO with a User Name: User/Login Name: _______________________________ The username cannot contain any spaces or special characters Please supply a list of additional Providers associated with your Office or Billing Office with each Provider signing next to their name: Provider Name: ________________________ Signature: ___________________ Provider Name: ________________________ Signature: ___________________ Provider Name: ________________________ Signature: ___________________ Provider Name: ________________________ Signature: ___________________ Provider Name: ________________________ Signature: ___________________ Provider Name: ________________________ Signature: ___________________ Provider Name: ________________________ Signature: ___________________ Once the information from your office has been verified, we will E-mail you a unique password and link to the web site. We will not send the user name for security purposes in this e-mail. This authorization is to remain in full force and effect until Provider received written or verbal notification from Central Health MSO, Inc. of its termination in such time and in such manner as to afford Provider opportunity to act on it. Primary Provider Signature: _______________________ Date: ___________ Please supply the following requested information: **Contact Name: ______________________________________ **Contact Phone: ______________________________________ **Contact E-mail: ______________________________________ ** All E-mail Addresses and Telephone Numbers will be verified to use web application. All information for verification and password or password re-setting will be sent to Contact. Fax Application to (626) 388-2356
Or Mail to:
Central Health MSO, Inc.
1540 Bridgegate Drive
Diamond Bar, CA 91765
Attn: IS Dept / Web Application
Internal Use Only
All Providers Verified by: _____________ Provider E-Mail Address Verified by: ____________ Date: ________ Provider Phone # Verified by: ________________ Date: ________ Contact E-Mail Address Verified by: ____________ Date: ________ Contact Phone # Verified by: ________________ Date: ________ E-Mail Password and Link by: ________________ Date: ________ Central Health MSO, Inc. – Information Systems Department

Source: http://www.chmso.org/application_form.pdf