Local Admin Registration

I am requesting Supervisor Level Access Rights to the CHCN Web Portal for the Managed Care business purposes of the health care company listed below. These Supervisor rights will allow me to request User rights for employees of my company.

Please agree that you have 'read and agree' to these HIPAA-related provisions:

• I understand that I, and those I authorize, are being given access to legally protected, individually identifiable health information that is subject to the privacy rules of the US, the State of California, and local governments.
• I understand and agree that my access to patient information and access for those to whom I authorize, is limited to my company's managed care business with CHCN.
• I understand that access to this information is granted on an individual basis and is not transferable. Thus, logins or passwords will not be shared with others.
• I understand that if provided accidental access to unauthorized information, this information will not be copied, or retained, and will be reported to CHCN.
  • The persons on the following page, for whom I am requesting access to the CHCN Web Portal Managed Care module, are employees of my company, and require access for their job duties.
  • The persons for whom I am requesting access to the CHCN Web Portal Managed Care module, have been informed of, and agree to points 1-4 above.
  • I agree to promptly inform CHCN when I, or persons to whom I have authorized access, will no longer require CHCN Web Portal Managed Care module access rights.

Any breach of this policy, even an inadvertent disclosure of confidentiality, is a basis for the suspension of access rights.