Read Microsoft Word - BMC HPP & HPF Access & Confidentiality Form.doc text version

615 N. Bonita Avenue, Panama City, FL 32401

Horizon Provider Portal (HPP) & Horizon Patient Folder (HPF)

Each person requesting access to HPP and/or HPF must fill out this form.

Legal First / Middle / Last Name Bay Medical Physician ID (physicians only) Practice Name List of All Physicians, PAs, & NPs in Practice

Practice Phone & Fax Numbers Contact for scheduling training

(include email to facilitate scheduling)

Phone: Name: Email Address:


Practice Address Practice City, State, & Zip Last 4 digits of SSN Specialty or Job Title

HPP & HPF Confidentiality and Security Agreement

1. When I receive my System User Name(s) and Password(s), I will assume responsibility for the proper use of my Password for access to patient information related Treatment, Payment, and Health Care Operations. I understand my Security Password code is individualized and is not to be given to or shared with any other person for any reason. 2. I understand that assurance of confidentiality is an essential part of establishing a community of trust for both givers and receivers of care. I understand that confidentiality of any information pertaining to the care and treatment of all patients, including specific information contained in the patient's medical record viewed through the BMC HPP and HPF is to be maintained at all times. 3. I understand that the unauthorized disclosure of confidential information is prohibited by the Health Insurance Portability and Accountability Act (HIPAA) and any violations may result in civil and/or criminal action. 4. I will not access patient information unless I need to know this information in order to perform my job. This includes accessing my own medical or other confidential information. 5. I understand access to patient information via HPP and HPF is periodically audited. I have read and agree with the above conditions:

Signature Date

Please fax completed form to Bay Medical Center's HIPAA Privacy & Security Office: 850-747-6443 or email to [email protected] Questions? Please call Karla Seaborn at 850-747-6670.


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