CHI St.

Lukes Health System Access Request Form for Physician Office Employees_____
Please complete and return the completed form to Fax# 713-610-2177

Applicant Information (Please print) Please note: All fields are Mandatory.

Last Name____________________________ First Name _____________________________ Middle Initial________

E-mail address: ____________________________________________ Professional Title (i.e. MD, RN): _________________

Work phone: ________________________________________ Existing User ID: _____________________________

Last 4 Number of Social Security: _________________________ Last 2 Digits of Year of Birth: ____________________

Please specify Job Role:

Office Manager - Records
rd rd
Party Biller, 3 Party Billing Company Name_________________________________________ Med Student START DATE___________
_____________________________ Med Student END DATE___________

Physician Name (PLEASE PRINT CLEARLY) __________________________________________________________________

Office Street Address, Suite #__________________________________________________________________________________

Physician Group or Vendor Name (PLEASE PRINT CLEARLY) _______________________________________________________________

Physician/Vendor Approval Signature, Office Employee Signature REQUIRED.
Both signatures acknowledge the confidentiality agreement detailed below.
I am employed by the physician/vendor as indicated above and hereby acknowledge that I have been granted the right to use the
hospitals computer based patient information system and on behalf of myself, I understand and agree to maintain the confidentiality
of all information accessible through the system, such as financial and demographic data, physician orders, order status, test results,
schedules and other patient and confidential hospital information.

I understand and agree that I am given access to this system for the sole purpose of providing patient care/consulting services and
agree to use such confidential information as is minimally necessary to carry out services provided in this Agreement. I understand
and agree not to copy or record any confidential patient or hospital information for my own personal use. Further, I understand any
information obtained from such access to the patient information system may not be disseminated, divulged, sold, transferred or in any
way communicated to any other person(s), company and/or firm for any purpose, patient care excepted, without the expressed written
consent of the patient and/or CHI St. Lukes Health System.

I understand that any breach in the confidentiality or privacy of confidential information may result in corrective action, up to and
including automatic termination of the privilege to access the hospitals computer based patient information system, discharge, or loss
of clinical privileges.

Confidentiality of Computer Log-in IDs and Passwords

As required by law and Health System Policies, each person requesting computer access to proprietary information, including
protected health information, is granted a unique log-in ID and password. Each person will be held accountable for security breaches
that can be traced to their log-in ID and password. Sharing of passwords is strictly prohibited. Each person should sign on to
computer systems with their own unique log-in ID and password. Violations may result in corrective action, up to and including
discharge, loss of access, or loss of clinical privileges.

Office Employee Signature: ________________________________________________________ Date: _____________

Physicians/Vendor Authorization Signature: __________________________________________Date: _____________