Records Access Agreement
For External Users
Security, confidentiality, and data integrity are matters of concern for all persons who have access to any health plan
records that contain (PHI (“Record”). Each person who accesses the Records must recognize these responsibilities and be
entrusted in their preservation. There are distinct differences between paper Records and electronic Records. This document
deals with use of and access to electronic Records and, as appropriate, to paper Records as well. You are being afforded
access to certain Records as part of the University Health Plan’s Treatment, Payment, or Health Care Operations. Before being
afforded access privileges, all authorized persons must read and agree to comply with this Agreement.
The following specific principles concerning security, confidentiality, and integrity of the Health Plan’s Member
electronic information are applicable to all persons who are authorized to access these Records.
In exchange for being granted access to the Health Plan’s electronic Member information, I agree that I will:
Access only those Records that are necessary for the purpose for which my access has been granted as
Not release my assigned user identification or password (electronic signature/authentication device
where applicable) to anyone else, or intentionally/unintentionally allow anyone else to access or alter
information using my user identification.
"Lock" the computer when I leave the workspace by selecting the "CTRL," "ALT," "DEL" keys.
Not utilize anyone else's user identification or password to access Records or alter information. I will
exit to the logon window when I am not at the workstation.
Understand that the information accessed contains sensitive and confidential Member information
that may be disclosed only to those authorized to receive it.
Respect the privacy and rules governing the use of confidential information accessible through
electronic information systems including but not limited to HIPAA and HITECH and utilize only such
information to perform my legitimate duties.
Understand that all access, attempts to access, and accomplishment of specific functions (e.g., entry
and authentication of information, access to Records identified as sensitive, accumulation of
unsigned documents) will be monitored and are subject to review by the University Health Plan.
Respect the confidentiality of any reports containing Member information printed from the system
and handle, store, use, and dispose of these reports appropriately.
Understand that the authentication (electronically signing) of documents will be treated as a written
signature with all the ethical, business, and legal implications associated thereof.
Not divulge, copy, benefit personally, alter or destroy, or remove either electronic or hard copy from the
premises any information contained within the Records except as properly authorized by the University
Health Plan and within the scope of my professional duties.
Understand that I have no right or ownership interest in information within the electronic system
and that my access code may be revoked at any time.
Violators of this Agreement may be subject to loss of access. By signing this, I agree that I have read, understand,
and will comply with this Agreement.
Purpose for Requested Access:
For Administrator only:
User ID: Activate Date: Deactivation Date:
Rev: 01/2015 © 2015