VCC Link System Access Request Form - Virginia Commonwealth ...

VCC Link System Access Request FormPlease send the completed form to Virginia Coordinated Care, attention Kim LewisFax: (804) 628-0532 Email: klewis@mcvh-vcu.edu□ New Request □ Change Request □ Account DeletionName: _____________________________ Date: _______________ Phone: (__)______________Email: _____________________________Job Title: ____________________________Physician: _______________________________Practice: ___________________________________AcknowledgementAccess to the VCC Link network is a privilege. I hereby acknowledge that remote access is authorized for myuse only and that all passwords and users names are to be kept confidential at all times. By requesting a remoteaccess account, I acknowledge that I will install or already have installed virus protection software on mycomputer system (this includes business, home or laptop). In addition, I authorize VCUHS and/or theircontractor to perform random port scans to assess the security, when needed, of the connection to the VCUHSnetwork. Installation of the virus protection and applying virus signature updates is my responsibility. Iunderstand that failure to do so may result in loss of remote access privileges. VCUHS employees are notresponsible for any operation system, hardware or software application problems encountered by any VCUHSRemote Access User, when using the designated applications to connect to the VCUHS network(s).Confidentiality AgreementAccess to confidential information is permitted only on a need to know basis. I acknowledge and understandthat I may have access to proprietary or other confidential business information belonging to the VCU HealthSystem (VCUHS). In addition, I acknowledge and understand that I may have access to confidentialinformation regarding VCUHS patients. Therefore, except as required by my role or by law, I agree that I willnot (a) access data that is unrelated to my job duties and (b) disclose to any other person, or allow any otherperson access to, any information related to VCC Link, which is proprietary or confidential and/or pertains topatients or patient care. “Disclosure of information” includes, but is not limited to, verbal discussions, FAXtransmissions, electronic mail messages, voice mail communication, written documentation, “loaning’ computeraccess codes, and/or another electronic transmission or sharing of data. I understand that VCUHS, theirpatients, staff or others may suffer irreparable harm by disclosure of proprietary or confidential information andthat VCUHS may seek legal remedies available to it should such disclosure occur. Further, I understand thatviolations of this agreement or any other VCUHS policy regarding confidentiality may result termination ofrelationship with VCUHS.My signature below indicates that I have read, understand, and agree to abide by the terms and conditions of theAcknowledgement and Confidentiality Agreement statements above.User’s Signature: _______________________________________Supervisor’s Signature: __________________________________Date: ____________________Date: ____________________

Information ServicesRemote Site Security Contact AgreementIt is the policy of the VCUHS to protect the confidentiality of all data, particularly patient data. Remote sitesecurity contacts are responsible for assisting users with User ID/password problems by serving as the contactpoint between the VCC staff and users at the remote location. As a remote site security contact you are subjectto the following conditions and terms:1. I will use VCC Link information and data to conduct business only.2. I will request user ID and password resets only for users who have locked themselves outof the system or have forgotten their password.3. I will only give a password to the user who owns that User ID.4. I will never use a User ID or password that belongs to another user.5. If I have any reason to believe that a User ID or password at my location has beencompromised, I will report it to the VCC Link Liaison immediately.6. I understand I will be held responsible for the consequences of any system misuse due tonegligence on my part.7. I will respect confidentiality of all patient, private, or sensitive information accessed inthe VCC Link information system. I am aware that every system user is responsible forthe safekeeping and handling of financial, medical, patient and personal information toprevent unauthorized disclosure.8. I understand that I will be held responsible for the intentional misrepresentation of data.9. I agree to use my authority as a remote site security contact only to perform tasks ofwhich I have responsibility or proper authorization.10. I agree to follow the system access policies and procedures established by VCUHS.Failure to follow system access policies and procedures may result in revocation of mysystem privileges and, where applicable, criminal charges.My signature below indicates that I have read, understand, and agree to abide by the terms and conditions of theRemote Site Security Contract Agreement.__________________________________Signature__________________________________Name (Printed)__________________________________Telephone Number__________________________________Date__________________________________Practice Name__________________________________Email Address