ENGLEWOODHOSPITAL AND MEDICALCENTER
Information Technology Department
PHYSICIAN’S SYSTEMS & REMOTE ACCESS
USER INFORMATION (* mandatory fields-please print legibly)
Physician/NP/PA/CRNA etc. Office Staff
*Name: ______*______*______
(Print First Name)(Print Middle Initial)(Print Last Name) (Title – MD, RN, etc)
*Contact Telephone/Ext: ______
*External Email address:______
*Practice Address: ______
______
Revised 05/12/2010
*Practice Name: ______
(if applicable)
In order to ensure confidentiality of Patient medical records and appropriate system access in accordance with each employee’s job description, this form must be completed and authorized by the appropriate Physician Representative of the practice whenever a new access sign-on code is requested or an existing system access sign-on code is revised
The following items must be adhered to:
Physicians will have the same access they currently have within the Medical Center; selected office staff will have retrieval access to that physician’s/group current patients only. All staff must receive system training before access
codes are released. All staff accessing EHMC systems must complete a User Information Access Terms & Conditions Form. Physicians are responsible for notifying EHMC IT Department whenever an individual who has EHMC system access leaves the practice for any reason.
Revised 05/12/2010
REQUEST SYSTEMS ACCESS FOR: - Attachment to Policies #500.2 & #500.4
REMOTE ACCESS (VPN/Aventail)
Windows Mac
MEDICITY (Physician Portal - Clinical HIS,includes PACs, WebESA etc.)
ECLIPSYS for remote (Clinical HIS application)
WEB ESA (Electronic Signature)-physicians only
Additional form from Med. Records req’d.~Fax ESA form to (201) 871-4995
INTERGRAD (PACs/X ray etc.)- physicians only
METAVISION (Anesthesia)- anesthesia dept. only
OTHER: ______
Revised 05/12/2010
APPROVAL:
*PHYSICIAN SIGNATURE: ______DATE: ______
***No Network access will be granted to private office staff without Physician approval***
******** Forward completed form to IT Department, FAX # 201-894-8380 *******
______
* Asterisk indicates a mandatory information field. Incomplete form will result in delay in systems access
Revised 05/12/2010
ENGLEWOODHOSPITAL AND MEDICALCENTER
INFORMATION ACCESS TERMS AND CONDITIONS
The following Information Access Terms and Conditions include, but are not limited to:
- Confidentiality:
EHMC data, whether hard copy or via the computer, is the property of the MedicalCenter. The data is confidential and is not to be disclosed, viewed or shared by anyone other than authorized personnel. This confidential information is PHI (Protected Health Information) and includes most identifiable health information related to the healthcare and payment for healthcare of a patient (including demographic information). This statement includes employees as well [Ref. CFR 142.308(a)(5) and 142.308(d)(1)(ii)(A)].
- Password/ID Sharing:
Users are not allowed to share IDs or passwords. This is in accordance with the EHMC Password and ID Policy and Procedure #500.4. Violations can be tracked and logged. A memorandum will be submitted to your Supervisor advising him/her of the violation and may cause your access rights to be restricted or eliminated. Periodic password changes will be required by the system software. Users should log out when leaving their terminals unattended.
- Hardware Installations:
All computer related hardware that is to be connected to any EHMC network must be installed by the Information Technology Department. Any hardware connected without the knowledge of the IT Department is a violation of procedure.
Remote access only: All computer hardware installation and configuration, and the verification of connectivity to an ISP is the responsibility of the Physician’s office.
- Software Installations/Upgrades:
No software can be added to a network or stand-alone PC by any person/department other than IT under any circumstances. This includes downloading software, screen savers, etc. from the Internet. This is in accordance with the EHMC Software License Compliance Policy and Procedure #500.3. If you are interested in a particular software package/upgrade, please submit a written request for IT consideration or contact the IT Help Desk at extension 3483. Requests will be accommodated according to available IT resources.
Remote access only: The software that is used to connect the Physician Office Network / individual Physician practices to the EHMC VPN is industry standard Microsoft Windows compatible.
- Network Maintenance:
If a Network Username remains inactive for more than one year, the Username will be removed from all EHMC systems. New Network Access forms must be resubmitted to create an account.
All network data is backed up on a daily basis. Any request to restore data must be submitted to IT and there will be a 48 hour turnaround to restore data.
______
I have read this document and agree to the terms and conditions listed above.
Signed:______Date:______
Print Name:______Phone Number:______
Private Practice (name of): ______
Address of Practice: ______
______
Revised 05/12/2010