ORGANIZATIONUSERAPPLICATION
FORACCESSTOSTATEOFARIZONAHEALTHEARIZONAPLUS
________________________________________________________________________
StateofArizona Page1of5
PleaseidentifyalloftheindividualsforwhomyouarerequestingHEAplususersaccountaccess:including:
Employeesofyourorganization
Employeesoforganizationsyoucontractwithtoprovideapplicationassistanceatyourfacilities,
EachpersonyoulistonthisformmustcompleteandsignanIndividualUserApplicationbef
oreaccessto
HEApluscanbeapprovedbyAHCCCS.
Pleasereturnallpagesofthisformbyemailto:HEAAHCCCS@azahcccs.gov
1. TYPEOFREQUEST
(Checkonlyone):
NEW(
Organization’sinitialaccesstoHEAplus)

ADD/REMOVEUSERS
(Listonlythepersonsyouareaddingorremoving)
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___________________________________________________________________________________________
2. ORGANIZATIONINFORMATION
NameofSubscriberOrganization
MainAddressofOrganization
___________________________________________________________________________________________
3. PERSONCOMPLETINGTHISREQUEST
FirstName
LastName
Title
OfficeTelephone(includeExtension)
EMailAddress
___________________________________________________________________________________________
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Print Form
ORGANIZATIONUSERAPPLICATION
FORACCESSTOSTATEOFARIZONAHEALTHEARIZONAPLUS
________________________________________________________________________
StateofArizona Page2of5
4. EMPLOYEES
IattestthatthisorganizationusedthefollowingpracticesinhiringthepersonsforwhomIamrequesting
useraccountsinHEAplus.
(Checkallthatapply)
I9EmploymentEligibilityVerification


EVerify
BackgroundCheck

BiometricsCheck(fingerprint)
Other(Pleaseprovideadetaileddescription):_______________________________________________


IamspecifyingthattheemployeeslistedbelowbeeitheraddedasauserinHealtheArizonainconjunction
withthisorganization’sHealtheArizonaPlus SubscriptionAgreementorremovedasaHEAplususerfor
thisorganization.PleaseensurethatHEAplusaccountshavebeendeactivatedforpersonsyouare
removing.
AddorRemove? FirstName LastName WorkEmail

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ORGANIZATIONUSERAPPLICATION
FORACCESSTOSTATEOFARIZONAHEALTHEARIZONAPLUS
________________________________________________________________________
StateofArizona Page3of5
STAFFOFCONTRACTEDORGANIZATIONS/AGENCIES
Iattestthatthisorganizationutilizesstafffromcontractorstofulfillapplicationassistanceneedsofthis
organizationandrequiresinthecontractualagreementsthatthecontractor(s)usethefollowingpracticesin
hiringthepersonsforwhomIamrequestinguser accountsinHEAplus.
(Checkallthatapply
)
I9EmploymentEligibilityVerification


EVerify
BackgroundCheck

BiometricsCheck(fingerprint)
Other(Pleaseprovideadetaileddescription):_______________________________________________

Iamspecifyingthattheemployeesofacontractorofthisorganizationwhoarelistedbelowbeeitheradded
asauserinHealtheArizonainconjunctionwiththisorganization’sHealtheArizonaPlusSubscription
AgreementorremovedasaHEAplususerforthisorganization.PleaseensurethatHEAplusaccountshave
beendeactiv
atedforpersonsyouareremoving.
Addor
Remove?
FirstName LastName WorkEmail Contractor
Organization/
Agency
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ORGANIZATIONUSERAPPLICATION
FORACCESSTOSTATEOFARIZONAHEALTHEARIZONAPLUS
________________________________________________________________________
StateofArizona Page4of5
PRIVACYACTSTATEMENT
Theinformationonthisformiscollectedandmaintainedandusedforassigning,controlling,
tracking,andreportingauthorizedaccesstoanduseoftheStateofArizona’sHealtheArizonaPlus
computerizedinformationandresources.ThePrivacyActprohibitsdisclosure
ofinformationfrom
recordsprotectedbythestatute,exceptinlimitedcircumstances.
The information you furnish on this form will be maintained in the Individuals AuthorizedAccess
to the StateofArizona’sHealtheArizonaPlusSystemandmaybedisclosedasaroutineuse
disclosure
undertheroutineusesestablishedforthis system.
SECURITYREQUIREMENTSFORUSERSOFTHESTATEOFARIZONAHEALTHEARIZONAPLUS
TheStateofArizonaHealtheArizonaPlussystemcontainssensitiveinformationtocarryoutits
mission.Sensitiveinformationisany
information,whichtheloss,misuse,orunauthorizedaccess
to,ormodificationofcouldadverselyaffecttheprivacytowhichindividualsareentitledunderthe
PrivacyAct.
ToensurethesecurityandprivacyofsensitiveinformationinFederallysupported
computersystems,theComputerSecurityAct
of1987requiresagenciestoidentifysensitive
computersystems,conductcomputersecuritytraining,anddevelop
computersecurityplans.
Arizonamaintainsasystemofrecordsforuseinassigning,controlling,tracking,andreporting
authorizedaccesstoanduseofArizona’sco mputerizedinformationandresources.Arizonarecords
allaccesstoits
computersystemsandconductsroutinereviewsforunauthorizedaccesstoand/or
illegalactivity.
AnyonewithaccesstotheStateofArizona’sHealtheArizonaPlussystemcontainingsensitive
informationmustabidebythefollowing:
Donot disclose orlend your IDENTIFICATIONNUMBER AND/OR PASSWORD tosomeone
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.
DonotbrowseoruseArizonadatafilesforunauthorizedorillegalpurposes.
Donot useArizona datafilesfor privategainor tomisrepresent yourselforArizona.
Do notmake any disclosure of Arizona data thatis not specifically authorized.
Donotduplicate Arizonadatafiles,create subfilesofsuch records,removeortransmitdata
unlessyouhavebeen
specifically authorized to do so.
Do notchange, delete,or otherwise alter Arizona data files unless you havebeen
specifically authorized to
doso.
Donotmakecopiesofdatafiles,withidentifiabledata,ordatathatwouldallow
individualidentitiestobe
deducedunlessyouhavebeenspecificallyauthorizedtodoso.
DonotintentionallycausecorruptionordisruptionofArizonadatafiles.
Aviolationofthesesecurityrequirementscould resultinterminationofsystemsaccessprivileges
and/ordisciplinary/
adverse action, depending upon the seriousness of the offense. In
addition,
Federal, State,and/or local laws may providecriminal penalties for any person illegallyaccessing
or using a
Governmentowned or operated computer system illegally.
ORGANIZATIONUSERAPPLICATION
FORACCESSTOSTATEOFARIZONAHEALTHEARIZONAPLUS
________________________________________________________________________
StateofArizona Page5of5
If you become aware of any violation of these security requirementsor suspect that your
identification number
orpassword may have been usedby someoneelse,immediately report
thatinformation.
SIGNATURE
Bysigningthisformonbehalfofmyorganization,IamdeclaringthatIhavereadandunderstandthesecurityrequirements
relatedtheuseofHealtheArizonaPlusandpenaltiesforviolationsoftheserequirements.IdeclarethattheinformationI
providedinthisdocumentiscorrect.
Iunderstandth
atinthefutureImustsubmitthisdocumenttorequestanychangesinthepersonsforwhomIam
requestingaccesstoHealtheArizonaPlusundermyorganization’sHealtheArizonaSubscriptionAgreement.
PrintedName
Applicant’sSignature
Date
Please return all pages of this form by email to: HEAAHCCCS@azahcccs.gov