____________________________________________
Cameron University
Health Plan
Role-Based Access Worksheet*
Member Name:
Job Title:
College/Department/Clinic:
Supervisor:
(PHI = Protected Health
Information)
Type of Use – check all that are applicable
Type of PHI Member
Needs to Access
No access to PHI
needed to do the job.
Entire Designated
Record Set
Stored PHI (on or-off
site)
Be primary source of documentation and/or make entries under the direction of the provider or supervisor.
Change incorrect data and/or transcribe data.
Read to make decisions appropriate for position.
View information but not make revisions or additions.
Convey the information to persons or entities outside of the Health Plan.
Move information from one place to another.
Make final legal disposition of the records.
I understand that my access to and use of Protected Health Information created, obtained, and/or maintained by the University Health Plan is
limited to the types and uses indicated on this worksheet. I agree to seek permission from my supervisor prior to using Protected Health
Information in any manner not permitted by this worksheet.
I understand that if I use or disclose Protected Health Information in violation of this worksheet, the Health Plan’s Privacy or Security Policies, or
federal or state privacy laws, I will be subject to sanctions, which may include but are not limited to, termination.
**Supervisor
Member Signature
Date
Date
*To be completed for all members and volunteers of the Health Plan of the University by the employee’s or volunteer’s
supervisor. Must be updated as necessary to reflect changes in responsibilities.
**
I affirm that the types of uses indicated above are consistent with the member’s access to PHI.
1/2015 © 2015 Copy to Member HIPAA Document File in Department Files
