Provider Online Access Form - Memorial Hermann Health Solutions

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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
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Provider Online Access Form - Memorial Hermann Health Solutions

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