Fillable CHIA INET USER AGREEMENT Other Provider (Center for Health Information and Analysis)

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CHIA INET USER AGREEMENT Other Provider (Center for Health Information and Analysis)

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The CHIA INET USER AGREEMENT Other Provider (Center for Health Information and Analysis) form is 2 pages long and contains:

  • 1 signature
  • 17 check-boxes
  • 30 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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As an employee of
OR as an employee of a contractor of
I will be allowed to access CHIA-INET, the data reporting system provided to
by the Center for Health Information and Analysis
subject to the following terms and conditions:
Mr. Ms.
Mrs Dr.
• I will not disclose my CHIA-INET user ID and password to any other person.
• I will not attempt to access or look at CHIA-INET data other than what is required to perform my job.
• I will use any data I receive from CHIA-INET only as permitted and only in furtherance of my job.
• I will not share any data I receive from CHIA-INET with others unless doing so is necessary to do my job
(pertains to patient level condential data only).
• I will discuss data I receive from CHIA-INET 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 condential data only).
• I will not disclose any data that I receive from CHIA-INET to any third party unless I have specic written
permission from my supervisor or the legal order of a court (pertains to patient level condential 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 INET USER AGREEMENT
Other Provider
REQUIRED INFORMATION – please print and no abbreviations
. Name:
Job Title:
Company Name and Department:
Work Mailing Address:
E-mail Address:
Work Telephone:
Work Fax:
User Signature: Date:
(Please provide middle name initial)
(Required to send User ID and Password information)
Provider User Agreement - Page 1 of 2
MassHealth Provider ID# with Location. This consists of 9 numbers
for the Provider ID# and 1 Letter for the Location (i.e. 123456789A)
(if more than one entity is applicable please attach and submit a list of all entities, including the entity’s MassHealth Provider ID, with this Agreement)
(if more than one entity is applicable please attach and submit a list of all entities, including the entity’s
MassHealth Provider ID, with this Agreement)
click to sign
signature
click to edit
City or Town of Birth:
Security Questions - please select a Security Question below:
Answer:
Security questions are used by the Help Desk staff to ensure they are speaking with the correct person.
When an INET User calls for assistance and requires using condential information or sensitive issues,
the Help Desk will use security questions as a means to conrm the identity of the caller.
Check the type of access for this User Agreement
User Prole (check one) Functions
Data Reporter’s INET
Administrator
The person responsible for CHIA-INET 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.
USER’S INET WEB SECURITY ITEMS – required
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
ORGANIZATION(S) PROVIDER TYPE
Please specify your organization(s) provider type:
(if more than one entity is applicable please attach and submit a list of all entities with this Agreement)
Provider User Agreement - Page 2 of 2
Adult Day Health (ADH) Cost Report Submission
Adult Foster Care (AFC) Cost Report Submission
Ambulance Cost Report Submission
Community Health Centers Cost Report Submission
Day Habilitation Program Supplemental Survey
Group Adult Foster Care
Nursing Services Cost Report
Provider Submissions -
Only check the submissions that User will submit
or have access to under this Agreement
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CHIA INET USER AGREEMENT Other Provider (Center for Health Information and Analysis)

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Completed 20 July 2020

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