FMC - Forms

401 North Ewing Street
Lancaster, Ohio 43130

Systems Access Security Agreement 2019

Agreement submissions will be processed within 10 business days.

Are you a Practitioner or
Advanced Practice Provider?
Yes No
Must be a valid email address. Minimum length 5 characters.
Are you renewing for 2019? Yes No
Your Name:
First Name: Last Name:
or enter a company/office not in the list above.

Enter full Company name. No abbreviations. Minimum length 5 characters.
Enter full Title/Position. No abbreviations. Minimum length 5 characters.
Phone: Format: 740-555-5555
  Fax: Format: 740-555-5555
Date of Birth:
Month Day Year

Enter full Supervisor name. No abbreviations. Minimum length 5 characters.
Enter full Title/Position. No abbreviations. Minimum length 5 characters.
Supervisor Email:
Must be a valid email address. Minimum length 5 characters.
Supervisor Phone: Format: 740-555-5555

1. I understand that my system access is a function of my official duties and employment status:

System access is subject to annual renewal, and may be reviewed, modified, or revoked in the event that a system userís duties or employment status changes

b. Accounts can be disabled or revoked at any time Ė with or without notification - in the interest of network security.
c. System access will be deactivated after 90 days of non-use, and accounts will be deleted with the termination of employment.
d. The Systems Department maintains an audit trail of accesses to patient information that records the user, date, and patient identification of all accesses to electronic medical records.
e. All information stored on Fairfield Medical Center devices is the property of Fairfield Medical Center.
f. I understand I can have no expectation of privacy using FMC internet, email, phones or other methods of communication.
2. I am required to protect my accounts, passwords, system, and any information that I access:
a. I am absolutely liable for all activity that takes place under my credentials
b. I am the only person authorized to use my password(s) and user ID(s) and I will not disclose them to anyone; nor will I attempt to learn or use another personís password(s)/user ID(s).
c. If I have reason to believe that the confidentiality of any password(s) or account(s) has been compromised I will contact the Systems Department immediately.
3. I agree to maintain the confidentiality of any electronic patient data that I access or otherwise encounter:
a. I will access protected health information only for the purposes of facilitating treatment, payment, or other approved hospital operations (which may include educational or research purposes).
b. I am required to either log-out of the computer or lock the screen before leaving my system unattended.
c. I will immediately report any known or suspected breach of the confidentiality of the system or records/data obtained from it to the Medical Information Services manager.
d. I understand that medical records confidentiality is required by law, and that there are statutes specifically mandating the confidentiality of, among other areas, mental health, HIV, and drug and alcohol-related treatment records.
e. No one may access their own medical record except in their normal business roll if no other staff are available to do so. Disclosure of these accesses must be made to FMC Compliance..
4. I understand that I am restricted in what I am allowed to do as a system user:
a. I will not attempt to alter any security software, filters, policy, or configuration on any hospital devices.
b. I will not load, install, or remove any software on a hospital device or on the Common Desktop without assistance or approval from the FMC Systems Department. (Including screensavers and Internet toolbars)..
c. I will not attempt to connect any unauthorized personal laptop, PC, or hand-held devices to unauthorized FMC wired or wireless networks.
d. I understand that if I do not accept these restrictions of access I may be denied access or have access terminated to relevant computer systems and networks.
e. I understand that any fraudulent application, breach of confidentiality, or other violation of the above provisions may result in disciplinary action ranging from termination of access to the system or appropriate disciplinary measures up to and including termination of employment by my employer.

By clicking the "Submit" button below I am stating I personally completed this form.
I have not allowed someone else to complete this form on my behalf. Falsification of this document can result in loss of access for both involved parties.

All required fields
must be complete to submit form. Red highlighted fields need to be corrected before submitting.


Submit button will not be available until ALL fields are completed correctly.