FMC Systems Access Security Agreement

Agreement submissions will be processed within 10 business days.

All fields/rows marked with a must be completed to submit the form.

Are you a Practitioner or Advanced Practice Provider?

Yes No

E-Mail:

Must be a valid email address. Minimum length 5 characters.

Are you renewing from a previous year?

Yes No

Your Name (first, middle and last name are required):

First Name:	Middle Name:	Last Name:
		Middle name is required!

Company/Office:

or
enter a company/office not in the list above. (No abbreviations. Minimum length 5 characters.)

Title/Position:

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

Security PIN:

Enter 4 numbers, please remember this number to access your account.
Confirm PIN:

PHI Access - Will you be accessing FMC patient information?

Yes, I need access to FMC�s EMR
No, I will not be accessing patient information
I need an FMC Badge to access doors
Other - Enter reason below:

Supervisor:

Enter full Supervisor name. No abbreviations. Minimum length 5 characters.

Title/Position:

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:

a.	System access is subject to annual renewal, and may be reviewed, modified, or revoked in the event that a system user�s duties or employment status changes
b.	Accounts can be disabled or revoked at any time � 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 person�s 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 FMC Department of Corporate Compliance.
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 the course of their normal business role if no other staff are available to do so. Disclosure of these accesses must be made to the Department of Corporate 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.