CHIA INTERFACE USER AGREEMENT
Hospital/Facility File Submissions
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:
REQUIRED INFORMATION – please print and no abbreviations
Company Name and Department:
Work Mailing Address:
User Signature: Date:
* CHIA Submissions is the newer portal. Both systems are in use.
(Please provide middle name initial)
(Required to send User ID and Password information)
Hospital User Agreement - Page 1 of 2
• I will not disclose my CHIA-INET/CHIA Submissions user ID and password to any other person.
• I will not attempt to access or look at CHIA-INET/CHIA Submissions data other than what is required to perform my job.
• I will use any data I receive from CHIA-INET/CHIA Submissions only as permitted and only in furtherance of my job.
• I will not share any data I receive from CHIA-INET/CHIA Submissions with others unless doing so is necessary to do my job
(pertains to patient level condential data only).
• I will discuss data I receive from CHIA-INET/CHIA Submissions 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 condential data only).
• I will not disclose any data that I receive from CHIA-INET/CHIA Submissions to any third party unless I have specic written
permission from my supervisor or the legal order of a court (pertains to patient level condential 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.
(If more than one hospital is applicable, please attach and submit a list of all hospitals afliated with this agreement)
(Please attach and submit a list of all hospitals afliated with this agreement)
click to sign
click to edit