North Texas Division Security Access Form

North Texas Division Security Access Form
Please Fax Form(s) To 469-484-0536
*Required Fields – SAF will only be processed if all fields are complete
*Type of request:
*Office Phone Number:
*Office Fax Number:
* Practice Name/Physician Name:
*Office Address:
*Requesting Access for which HCA facility:
*List all Physician Practice Names or Individual Physicians which you are affiliated
Limit two office staff per physician
*User Type:
*Name: (First, MI, Last)
(PA, NP, Office Staff)
(full social required)
*Physician Printed Name:
*Physician Signature:
Please have each individual listed above sign and date a Confidentiality & Security Agreement and
fax them with this form. If we do not have a Confidentiality & Security Agreement for each user we are unable
to process the request.
Once the completed forms have been received, you will be contacted by a Physician Support
Coordinator to schedule training.
Confidentiality and Security Agreement
I understand that the facility or business entity (the “Company”) for which I work, volunteer or provide services manages health
information as part of its mission to treat patients. Further, I understand that the Company has a legal and ethical responsibility to
safeguard the privacy of all patients and to protect the confidentiality of their patients’ health information. Additionally, the Company
must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning information, or
any information that contains Social Security numbers, health insurance claim numbers, passwords, PINs, encryption keys, credit card
or other financial account numbers (collectively, with patient identifiable health information, “Confidential Information”).
In the course of my employment/assignment at the Company, I understand that I may come into the possession of this type of
Confidential Information. I will access and use this information only when it is necessary to perform my job related duties in
accordance with the Company’s Privacy and Security Policies, which are available on the Company intranet (on the Security Page)
and the Internet (under Ethics & Compliance). I further understand that I must sign and comply with this Agreement in order to obtain
authorization for access to Confidential Information or Company systems.
General Rules
I will act in the best interest of the Company and in accordance with its Code of Conduct at all times during my
relationship with the Company.
I understand that I should have no expectation of privacy when using Company information systems. The Company
may log, access, review, and otherwise utilize information stored on or passing through its systems, including email, in
order to manage systems and enforce security.
I understand that violation of this Agreement may result in disciplinary action, up to and including termination of
employment, suspension, and loss of privileges, and/or termination of authorization to work within the Company, in
accordance with the Company’s policies.
Protecting Confidential Information
I will not disclose or discuss any Confidential Information with others, including friends or family, who do not have a
need to know it. I will not take media or documents containing Confidential Information home with me unless
specifically authorized to do so as part of my job.
I will not publish or disclose any Confidential Information to others using personal email, or to any Internet sites, or
through Internet blogs or sites such as Facebook or Twitter. I will only use such communication methods when
explicitly authorized to do so in support of Company business and within the permitted uses of Confidential Information
as governed by regulations such as HIPAA.
I will not in any way divulge, copy, release, sell, loan, alter, or destroy any Confidential Information except as properly
authorized. I will only reuse or destroy media in accordance with Company Information Security Standards and
Company record retention policy.
In the course of treating patients, I may need to orally communicate health information to or about patients. While I
understand that my first priority is treating patients, I will take reasonable safeguards to protect conversations from
unauthorized listeners. Such safeguards include, but are not limited to: lowering my voice or using private rooms or
areas where available.
I will not make any unauthorized transmissions, inquiries, modifications, or purgings of Confidential Information.
I will not transmit Confidential Information outside the Company network unless I am specifically authorized to do so
as part of my job responsibilities. If I do transmit Confidential Information outside of the Company using email or
other electronic communication methods, I will ensure that the Information is encrypted according to Company
Information Security Standards.
Following Appropriate Access
I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the operation
or function of systems or devices to unauthorized individuals.
I will only access software systems to review patient records or Company information when I have a business need to
know, as well as any necessary consent. By accessing a patient’s record or Company information, I am affirmatively
representing to the Company at the time of each access that I have the requisite business need to know and appropriate
consent, and the Company may rely on that representation in granting such access to me.
Using Portable Devices and Removable Media
I will not copy or store Confidential Information on removable media or portable devices such as laptops, personal
digital assistants (PDAs), cell phones, CDs, thumb drives, external hard drives, etc., unless specifically required to do so
by my job. If I do copy or store Confidential Information on removable media, I will encrypt the information while it is
on the media according to Company Information Security Standards
I understand that any mobile device (Smart phone, PDA, etc.) that synchronizes company data (e.g., Company email)
may contain Confidential Information and as a result, must be protected. Because of this, I understand and agree that
the Company has the right to:
a. Require the use of only encryption capable devices.
b. Prohibit data synchronization to devices that are not encryption capable or do not support the required security
c. Implement encryption and apply other necessary security controls (such as an access PIN and automatic
locking) on any mobile device that synchronizes company data regardless of it being a Company or personally
owned device.
d. Remotely "wipe" any synchronized device that: has been lost, stolen or belongs to a terminated employee or
affiliated partner.
e. Restrict access to any mobile application that poses a security risk to the Company network.
Doing My Part – Personal Security
I understand that I will be assigned a unique identifier (e.g., 3-4 User ID) to track my access and use of Confidential
Information and that the identifier is associated with my personal data provided as part of the initial and/or periodic
credentialing and/or employment verification processes.
I will:
a. Use only my officially assigned User-ID and password (and/or token (e.g., SecurID card)).
b. Use only approved licensed software.
c. Use a device with virus protection software.
I will never:
a. Disclose passwords, PINs, or access codes.
b. Use tools or techniques to break/exploit security measures.
c. Connect unauthorized systems or devices to the Company network.
I will practice good workstation security measures such as locking up diskettes when not in use, using screen savers
with activated passwords, positioning screens away from public view.
I will immediately notify my manager, Facility Information Security Official (FISO), Director of Information Security
Operations (DISO), or Facility or Corporate Client Support Services (CSS) help desk if:
a. my password has been seen, disclosed, or otherwise compromised;
b. media with Confidential Information stored on it has been lost or stolen;
c. I suspect a virus infection on any system;
d. I am aware of any activity that violates this agreement, privacy and security policies; or
e. I am aware of any other incident that could possibly have any adverse impact on Confidential Information or
Company systems.
Upon Termination
I agree that my obligations under this Agreement will continue after termination of my employment, expiration of my
contract, or my relationship ceases with the Company.
Upon termination, I will immediately return any documents or media containing Confidential Information to the
I understand that I have no right to any ownership interest in any Confidential Information accessed or created by me
during and in the scope of my relationship with the Company.
By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions
stated above.
Employee/Consultant/Vendor Signature
Facility Name and COID
Employee/Consultant/Vendor Printed Name
Business Entity Name