Request for
Electronic Access to UAMS MD-Link
System
Check One: Add ( ) Change ( ) Remove ( ) MD-Link access username and password for the following:
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Physician’s Full Name and Credentials:
__________________________________________
Telephone Number:_________________________
Office E-Mail Address_______________________
AR Medical License Number: _________________ |
Business/Clinic Name and Address:
____________________________________ Name of Business/Clinic ____________________________________ Address ____________________________________ City State Zip |
I have received a copy of the UAMS Confidentiality Policy. I agree to use and disclose UAMS patient information obtained from the UAMS MD-Link System only as allowed by the UAMS Confidentiality Policy and in accordance with applicable state and federal laws including the Health Insurance Portability and Accountability Act (HIPAA). I understand that revealing my password to anyone or allowing anyone the use of the system under my password is a violation of this Policy.
The confidentiality of patient medical data available from the computer is of equal importance to the confidentiality of data on the written medical record. I understand that improper use or disclosure of a patient's information or the sharing of my password is a very serious offense subject to permanent loss of access and may be subject to legal action.
I realize that UAMS logs all access to patient information via MD-Link and that this log is subject to regular review. If requested, I will provide written justification for my need to have accessed any patient's record.
Complete If Also Requesting Access for Staff Members
If I need a member of my staff to have electronic access to UAMS patient information via MD-Link, I may list below up to two (2) staff members who require such access to perform their respective job responsibilities. I acknowledge and accept supervisory responsibility for all usage of the UAMS MD-Link system by the staff listed below. I agree that the staff named below will be required to sign the UAMS Confidentiality Agreement, and I acknowledge that such staff members have received HIPAA training by our office. Office staff will be required to renew access annually.
______________________________________ _______________________ ______________________________
Office Staff Name Position/Title Office Email Address
______________________________________ _______________________ ______________________________
Office Staff Name Position/Title Office Email Address
I agree to promptly notify UAMS at 501-603-1440 in the event that any of the above listed staff are no longer employed by me; and in the event the staff member provides prior notice of his/her departure, I agree to notify UAMS prior to the effective date of employee’s separation from employment.
I hereby accept the terms and conditions as stated herein.
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_____________________________________ Physician Printed Name |
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_____________________________________ Physician Signature |
__________________________________ Date |