Fillable To participate in the Kansas Immunization Registry [KSWebIZ] (Kansas Department of Health and Environment)

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To participate in the Kansas Immunization Registry [KSWebIZ] (Kansas Department of Health and Environment)

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BROWSE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (KS) FORMS

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Page 1 of 2 Rev. 12/2017
SITE ENROLLMENT AGREEMENT
To participate in the Kansas Immunization Registry [KSWebIZ]
KSWebIZ
is an Internet-based immunization registry operated by the Immunization Program of the
Kansas Department of Health and Environment. Enrolled health care providers can obtain
immunization information for patients, including tracking and recall. Patient information is confidential
and is only available to the authorized users of the system.
Pursuant to K.S.A. 65-101, the Secretary of the Kansas Department of Health and Environment shall
exercise general health supervision of the health of the people of the State of Kansas; take action to
prevent the introduction and spread of infectious disease within the state; and provide public health
outreach services to the people of the state, including educational and other activities designed to
increase the individual’s awareness of public and other preventive services. A goal of KDHE is to
ensure that all citizens of the State of Kansas are properly and appropriately immunized against
preventable communicable diseases. Consistent with the authority of the Secretary to prevent the
introduction and spread of communicable diseases among the people of Kansas, the KSWebIZ program
has been established to enable KDHE to share selected immunization information and encourage
individuals to obtain appropriate and timely immunization.
Provid
er participation in KSWebIZ is voluntary.
Type of Organization: Public □ Private □
Local Health Department, Private Practice, Public School, Health Plan, etc.:
----------------------------------------------------------------------------------
Name of Health Care Provider/Organization:
__________________________________________________________
Number of Clinic Sites in Organization: _______
Provider/Organization’s Representative:
__________________________________________________________
Title of Organization’s Representative:
__________________________________________________________
Street Address: _____________________________________________
City: _________________Zip:_________ County:_____________ State: ____
Phone: ( ) _______________ Fax: ( ) ________________
Email: ____________________________________________________
VFC PIN #/SCHOOL DOE# ________________________
Page 2 of 2 Rev. 12/2017
As a condition of participating in KSWebIZ, the above-named Provider enters into this agreement with
the Kansas Department of Health and Environment to use KSWebIZ only for the immunization needs of
patients.
The provider/organization and affiliated staff will access the registry only to:
• Assure adequate immunization
• Avoid unnecessary immunizations
• Confirm compliance with mandatory immunization requirements
If this agreement is violated by any use of the system in an unauthorized manner, the Kansas
Department of Health and Environment reserves the right to immediately terminate the provider’s
access. Unauthorized use may also subject the provider to sanctions and penalties under state or
federal law.
The Provider shall abide by the requirements in the KSWebIZ Confidentiality Policy, which is
incorporated by reference into this agreement. Each provider employee having access to KSWebIZ
must sign the User Agreement, which must be kept in the employee’s personnel file.
The Provider will take all reasonable steps to assure employee compliance with confidentiality
requirements.
The Provider shall furnish the personal demographic and immunization information for the
individual receiving immunizations as required by the registry and strive for submission of such data
within one week of administering the immunization.
Providers may correct and/or update information pursuant to patient feedback/input.
_________________________________________ ________________
Signature of Provider or Authorized Representative Date
_________________________________________ ________________
Signature of KSWebIZ Authorized Representative Date
_________________________________________ ________________
Signature of KSWebIZ Program Manager Date
Attachment: KSWebIZ Confidentiality Policy
In the event the Provider discovers a suspected breach or intrusion of any of their electronic
systems that have a relationship to KSWebIZ, the user shall notify KDHE immediately (not to
exceed 4 hours from the discovery of the suspected breach or intrusion).
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To participate in the Kansas Immunization Registry KSWebIZ (Kansas Department of Health and Environment)

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Completed 6 October 2021

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