Provider Online Access Form - Memorial Hermann Health Solutions

Individual Provider/Provider’s Office Authorized User Access Request FormInstructions:Please complete the form and submit to Memorial Hermann Health Solution Insurance(MHHSI) Web Security Team via fax at 713-338-4118 or via email atmhhealtheligibility@memorialhermann.orgYou will be contacted by a Web Security specialist within three business days toreview this request.Check all that apply for the request and complete the form in its entirety.Create new user (complete Section 1)Modify existing user information /Terminate existing user access (complete Section 2)1 | P a g e

Individual Provider/Provider’s Office Authorized User Access Request FormSection 1 – Create new user access (Please fill out a separate form for each new user)Provider’s Name:Provider’s Office Location(s):City: State: Zip Code:Check to allow access to all Provider’s location(s):Provider’s Tax ID Number:Provider’s NPI Number:User’s First Name:User’s Last Name:User’s Job Title:User’s Date of Birth (mm/dd/yyyy) :User’s Phone #:User’s Email Address:2 | P a g e

Individual Provider/Provider’s Office Authorized User Access Request FormSection 2- Change existing user information / Terminate existing user’s accessUser ID:User Name:User’s Email:User’s Phone #:Please list below all the changes to be made to the above mentioned user’s account.For MHHSI information validation use only. Do not write in the below section.3 | P a g e

Individual Provider/Provider’s Office Authorized User Access Request FormAuthorizations/HIPAA disclaimerUser Name and Password confidentialityThe purpose of your User Name and password is to authenticate your identity to the computersystems. It is recommended to keep the User Name and password confidential.Confidentiality of informationAll information contained in Memorial Hermann Health Solutions Insurance (MHHSI) computersystem is confidential, and must not be disclosed.Examples of misuse of computer information systemsThe following list includes some examples of improper use of the privileges of using theinformation system:Accessing patient claims not related to current work responsibilities.Using another person’s User Name and password to gain access to any computersystem.Allowing another person to use a User Name and password assigned to you.Failing to log off at the end of a session, thus allowing another user to access dataand perform actions in your account.Using computer program when another user is signed on.By signing this document, I agree to the following to change my passwordIf I suspect that another person knows my password, I will immediately contact MHHSIWeb Security Team at 713-338-6535 or 888-642-5040.I understand that it is my responsibility to immediately notify MHHSI Web SecurityTeam at 713-338-6535 or 888-642-5040 of any staff terminations under my control sothat their access to the secure MHHSI site can be terminated.I understand that if I do not use my secure website User Name and password withinseven days that my account will be disabled and access to the secure website will4 | P a g e

Individual Provider/Provider’s Office Authorized User Access Request Formcease. I will have to contact the MHHSI Web Security Team at 713-338-6535 or 888-642-5040 to re-activate my account.Print User’s First & Last Name User’s Signature Date SignedSponsoring Provider’s / Provider’s Office Manager’s signature required for all UsersSponsoring provider: I agree that the above name employee has my authorization to accessmy patient’s claim data.Print Full Name Signature Date SignedFor Memorial Hermann Health Solutions Insurance use onlyUser ID assigned:Temporary password assigned:Provider’s Physician Number:Created/Modified on:ByContacted user via: On ByNotes:5 | P a g e