Fillable Arizona Health Care - Organization User Application Form

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Arizona Health Care - Organization User Application Form

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The Arizona Health Care - Organization User Application Form form is 5 pages long and contains:

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12 check-boxes
198 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Arizona Health Care Cost Containment System

BROWSE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AZ) FORMS

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ORGANIZATIONUSERAPPLICATION

FORACCESSTOSTATEOFARIZONAHEALTH‐E‐ARIZONAPLUS

________________________________________________________________________

StateofArizona Page1of5



PleaseidentifyalloftheindividualsforwhomyouarerequestingHEAplususersaccountaccess:including:

• Employeesofyourorganization

• Employeesoforganizationsyoucontractwithtoprovideapplicationassistanceatyourfacilities,

EachpersonyoulistonthisformmustcompleteandsignanIndividualUserApplicationbef

oreaccessto

HEApluscanbeapprovedbyAHCCCS.

Pleasereturnallpagesofthisformbyemailto:HEAAHCCCS@azahcccs.gov



1. TYPEOFREQUEST

(Checkonlyone):

NEW(

Organization’sinitialaccesstoHEAplus) 



ADD/REMOVEUSERS

(Listonlythepersonsyouareaddingorremoving)

 

___________________________________________________________________________________________

2. ORGANIZATIONINFORMATION

NameofSubscriberOrganization



MainAddressofOrganization



___________________________________________________________________________________________

3. PERSONCOMPLETINGTHISREQUEST

FirstName



LastName



Title



OfficeTelephone(includeExtension)



E‐MailAddress



___________________________________________________________________________________________



Print Form

ORGANIZATIONUSERAPPLICATION

FORACCESSTOSTATEOFARIZONAHEALTH‐E‐ARIZONAPLUS

________________________________________________________________________

StateofArizona Page2of5



4. EMPLOYEES

IattestthatthisorganizationusedthefollowingpracticesinhiringthepersonsforwhomIamrequesting

useraccountsinHEAplus.



(Checkallthatapply)



I‐9EmploymentEligibilityVerification

 



E‐Verify



BackgroundCheck 



BiometricsCheck(fingerprint) 



Other(Pleaseprovideadetaileddescription):_______________________________________________ 





IamspecifyingthattheemployeeslistedbelowbeeitheraddedasauserinHealth‐e‐Arizonainconjunction

withthisorganization’sHealth‐e‐ArizonaPlus SubscriptionAgreementorremovedasaHEAplususerfor

thisorganization.PleaseensurethatHEAplusaccountshavebeendeactivatedforpersonsyouare

removing.



AddorRemove? FirstName LastName WorkEmail







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ORGANIZATIONUSERAPPLICATION

FORACCESSTOSTATEOFARIZONAHEALTH‐E‐ARIZONAPLUS

________________________________________________________________________

StateofArizona Page3of5



STAFFOFCONTRACTEDORGANIZATIONS/AGENCIES

Iattestthatthisorganizationutilizesstafffromcontractorstofulfillapplicationassistanceneedsofthis

organizationandrequiresinthecontractualagreementsthatthecontractor(s)usethefollowingpracticesin

hiringthepersonsforwhomIamrequestinguser accountsinHEAplus.



(Checkallthatapply

)



I‐9EmploymentEligibilityVerification

 



E‐Verify



BackgroundCheck 



BiometricsCheck(fingerprint) 



Other(Pleaseprovideadetaileddescription):_______________________________________________





Iamspecifyingthattheemployeesofacontractorofthisorganizationwhoarelistedbelowbeeitheradded

asauserinHealth‐e‐Arizonainconjunctionwiththisorganization’sHealth‐e‐ArizonaPlusSubscription

AgreementorremovedasaHEAplususerforthisorganization.PleaseensurethatHEAplusaccountshave

beendeactiv

atedforpersonsyouareremoving.



Addor

Remove?

FirstName LastName WorkEmail Contractor

Organization/

Agency



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 

ORGANIZATIONUSERAPPLICATION

FORACCESSTOSTATEOFARIZONAHEALTH‐E‐ARIZONAPLUS

________________________________________________________________________

StateofArizona Page4of5



PRIVACYACTSTATEMENT

Theinformationonthisformiscollectedandmaintainedandusedforassigning,controlling,

tracking,andreportingauthorizedaccesstoanduseoftheStateofArizona’sHealth‐e‐ArizonaPlus

computerizedinformationandresources.ThePrivacyActprohibitsdisclosure



ofinformationfrom

recordsprotectedbythestatute,exceptinlimitedcircumstances.



The information you furnish on this form will be maintained in the Individuals AuthorizedAccess

to the StateofArizona’sHealth‐e‐ArizonaPlusSystemandmaybedisclosedasaroutineuse

disclosure



undertheroutineusesestablishedforthis system.



SECURITYREQUIREMENTSFORUSERSOFTHESTATEOFARIZONAHEALTH‐E‐ARIZONAPLUS

TheStateofArizonaHealth‐e‐ArizonaPlussystemcontainssensitiveinformationtocarryoutits

mission.Sensitiveinformationisany



information,whichtheloss,misuse,orunauthorizedaccess

to,ormodificationofcouldadverselyaffecttheprivacytowhichindividualsareentitledunderthe

PrivacyAct.



ToensurethesecurityandprivacyofsensitiveinformationinFederallysupported

computersystems,theComputerSecurityAct



of1987requiresagenciestoidentifysensitive

computersystems,conductcomputersecuritytraining,anddevelop



computersecurityplans.

Arizonamaintainsasystemofrecordsforuseinassigning,controlling,tracking,andreporting

authorizedaccesstoanduseofArizona’sco mputerizedinformationandresources.Arizonarecords

allaccesstoits



computersystemsandconductsroutinereviewsforunauthorizedaccesstoand/or

illegalactivity.



AnyonewithaccesstotheStateofArizona’sHealth‐e‐ArizonaPlussystemcontainingsensitive

informationmustabidebythefollowing:



•

Donot disclose orlend your IDENTIFICATIONNUMBER AND/OR PASSWORD tosomeone

else. They are for



your use only and serve as your electronic signature. This means that

you may be held responsible for the



consequences of unauthorized or illegal

transactions.



•

DonotbrowseoruseArizonadatafilesforunauthorizedorillegalpurposes.



•

Donot useArizona datafilesfor privategainor tomisrepresent yourselforArizona.



•

Do notmake any disclosure of Arizona data thatis not specifically authorized.



•

Donotduplicate Arizonadatafiles,create sub‐filesofsuch records,removeortransmitdata

unlessyouhavebeen



specifically authorized to do so.



•

Do notchange, delete,or otherwise alter Arizona data files unless you havebeen

specifically authorized to



doso.



•

Donotmakecopiesofdatafiles,withidentifiabledata,ordatathatwouldallow

individualidentitiestobe



deducedunlessyouhavebeenspecificallyauthorizedtodoso.



•

DonotintentionallycausecorruptionordisruptionofArizonadatafiles.



Aviolationofthesesecurityrequirementscould resultinterminationofsystemsaccessprivileges

and/ordisciplinary/



adverse action,  depending upon the seriousness of the offense. In



addition,

Federal, State,and/or local laws may providecriminal penalties for any person illegallyaccessing

or using a



Government‐owned or operated computer system illegally.

ORGANIZATIONUSERAPPLICATION

FORACCESSTOSTATEOFARIZONAHEALTH‐E‐ARIZONAPLUS

________________________________________________________________________

StateofArizona Page5of5



If you become aware  of any violation of these security requirementsor suspect that your

identification number



orpassword may have been usedby someoneelse,immediately report

thatinformation.



SIGNATURE

Bysigningthisformonbehalfofmyorganization,IamdeclaringthatIhavereadandunderstandthesecurityrequirements

relatedtheuseofHealth‐e‐ArizonaPlusandpenaltiesforviolationsoftheserequirements.IdeclarethattheinformationI

providedinthisdocumentiscorrect.

Iunderstandth

atinthefutureImustsubmitthisdocumenttorequestanychangesinthepersonsforwhomIam

requestingaccesstoHealth‐e‐ArizonaPlusundermyorganization’sHealth‐e‐ArizonaSubscriptionAgreement.

PrintedName



Applicant’sSignature



Date



Please return all pages of this form by email to: HEAAHCCCS@azahcccs.gov



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Arizona Health Care - Organization User Application Form

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Completed 7 May 2020

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