Fillable CHIA INTERFACE USER AGREEMENT Hospital/Facility File Submissions (Center for Health Information and Analysis)

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CHIA INTERFACE USER AGREEMENT Hospital/Facility File Submissions (Center for Health Information and Analysis)

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

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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
Mr. Ms.
Mrs. Dr.
Name:
Job Title:
Company Name and Department:
Work Mailing Address:
E-mail Address:
Work Telephone:
Work Fax:
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 condential 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 condential data only).
• I will not disclose any data that I receive from CHIA-INET/CHIA Submissions 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 Submissions.
(If more than one hospital is applicable, please attach and submit a list of all hospitals afliated with this agreement)
(Please attach and submit a list of all hospitals afliated 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 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
Administrator
The person responsible for CHIA-INET and 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 User
Ability to: submit information, download, edit, view and print reports.
CHIA Submissions
Annual Hospital Cost Report
Top Ten Highest Compensated Employees
Behavioral Health Inpatient Data (Case Mix)
Hospital Health System (HHS) Specify Name: (Includes hospital health system, hospital,
and physician organization data)
CHIA INET
Hospital Inpatient Data (Case Mix)
Outpatient Observation Data (Case Mix)
Emergency Department Data (Case Mix)
Date:
Version/Code:
Hospital User Agreement - Page 2 of 2
USER 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
Hospital Submissions -
Only check the submissions that User will submit
or have access to under this Agreement
Revision Date: 7_30_2019
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CHIA INTERFACE USER AGREEMENT HospitalFacility File Submissions (Center for Health Information and Analysis)

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Completed 20 July 2020

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