Fillable CHIA INET/CHIA Submissions Platform User Agreement Insurance Carrier (Center for Health Information and Analysis)

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CHIA INET/CHIA Submissions Platform User Agreement Insurance Carrier (Center for Health Information and Analysis)

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The CHIA INET/CHIA Submissions Platform User Agreement Insurance Carrier (Center for Health Information and Analysis) form is 2 pages long and contains:

  • 1 signature
  • 28 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Center for Health Information and Analysis

BROWSE CENTER FOR HEALTH INFORMATION AND ANALYSIS (MA) FORMS

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Insurance Carrier User Agreement - Page 1 of 2
!
!
CHIA INET/CHIA Submissions Platform
User Agreement
Insurance Carrier
!
As an employee of
OR as an employee
of
a contractor
of
I will be allowed to access CHIA-INET/CHIA Submissions , the data reporting system provided to
by the Center for Health Information and Analysis
subject to the following terms and conditions:
!
!
• I will not disclose my CHIA-INET/CHIA Submissions Platform user ID and password to any other person.
!
• I will not attempt to access or look at CHIA-INET/CHIA Submissions Platform data other than what is required to perform my job.
!
• I will use any data I receive from CHIA-INET/CHIA Submissions Platform only as permitted and only in furtherance of my job.
!
• I will not share any data I receive from CHIA-INET/CHIA Submissions Platform with others unless doing so is necessary to do my
job.(pertains to patient level confidential data only).
!
• I will discuss data I receive from CHIA-INET/CHIA Submissions Platform with others only as required to perform my job and will
conduct such conversations only in secure areas where I am unlikely to be overheard (pertains to patient level confidential data only).
!
• I will not disclose any data that I receive from CHIA-INET/CHIA Submissions Platform to any third party
unless I have specific written permission from my supervisor or the legal order of a court (pertains to
patient level confidential data only).
!
• I hereby acknowledge I have read the above terms and conditions and agree to be bound thereby as a condition of access
to and use of CHIA-INET/CHIA Submissions Platform.
!
REQUIRED INFORMATION – please print and no abbreviations
!
!
Mr. Ms.
Mrs.
D
r.
Name:
(Please provide middle name initial)
!
Job
T
itle:
Company Name and Department:
W
ork Mailing Address:
!
!
!
!
E-mail Address:
!
!
(Required to send User ID and Password information)
!
!
Work Telephone:
W
ork
Fax:
!
User Signature:
Date:
click to sign
signature
click to edit
Insurance Carrier User Agreement - Page 2 of 2
Insurance Carrier Submissions -
USER’S INET/Submissions Platform SECURITY ITEMS – required
City or Town of Birth:
Security Questions - please select a Security Question below:
Favorite Singer
Favorite Vacation Location
Favorite Sports Team
Favorite Hobby
Favorite Pet’s Name
Favorite Teacher’s Name
Anniversary Date
Father’s Middle Name
First Child’s Middle Name
Make, Model, and
Year
of
First Car
Answer:
Security questions are used by the Help Desk staff to ensure they are speaking with the correct person.
When an INET/Submissions User calls for assistance and requires using confidential information or
sensitive issues, the Help Desk will use security questions as a means to confirm the identity of the
caller.
Check the type of access for this User Agreement
User Profile (check one)
Functions
Data Reporter’s INET
Administrator
The person responsible for CHIA-INET/CHIA Submissions Administration
(creates and maintains web user accounts online and via paper forms).
Also has the ability to: submit information, download, edit, view and print reports.
Data Reporter’s
Individual INET User
Ability to: submit information, download, edit, view and print reports.
Only check the submissions that User will submit
or have access to under this Agreement
All Payer Claims Datasets (APCD) Medical Claim
APCD Dental Claim
APCD Pharmacy Claim
APCD Member Eligibility
APCD Product
APCD Provider
APCD Benefit Plan Control (for Risk Adjustment carriers only)
APCD Supplemental Diagnosis (for Risk Adjustment carriers only)
SFTP APCD Carrier Submitter
Chapter 288: Relative Prices
Chapter 288: Total Medical Expenses
Ch. 224: Alternative Payment Methods
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CHIA INETCHIA Submissions Platform User Agreement Insurance Carrier (Center for Health Information and Analysis)

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Completed 13 August 2020

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