Free Wisconsin Birth Defects Prevention & Surveillance System User Security & Confidentiality Agreement, F-40056 - Wisconsin


File Size: 46.3 kB
Pages: 1
Date: February 17, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS/DPH/BCHP/ Birth Defects Registry
Word Count: 417 Words, 3,505 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhfs.wisconsin.gov/forms/F4/F40056.pdf

Download Wisconsin Birth Defects Prevention & Surveillance System User Security & Confidentiality Agreement, F-40056 ( 46.3 kB)


Preview Wisconsin Birth Defects Prevention & Surveillance System User Security & Confidentiality Agreement, F-40056
DEPARTMENT OF HEALTH SERVICES Division of Public Health F- 40056 (12/03)

STATE OF WISCONSIN

WISCONSIN BIRTH DEFECTS PREVENTION & SURVEILLANCE SYSTEM USER SECURITY AND CONFIDENTIALITY AGREEMENT
Participation in the Wisconsin Birth Defects Prevention & Surveillance System (BDPSS), an electronic reporting system, is voluntary, however, completion of this agreement is required for use of the system. Fax completed form to 608-267-3824. User Name: ____________________________________ User ID: ____________________________ User Role: Provider-User Provider-Administrator BDPSS Administrator

Organization Name: __________________________________________________________________ Organization Address: ________________________________________________________________ ___________________________________________________ City ___________ State _________________ Zip

By signing this agreement, I agree to: 1. Comply with the Wisconsin Birth Defects Prevention & Surveillance System Security and Confidentiality Policy and my organization's standard policies and procedures for releasing identifying health information for clients. 2. Participate in and provide information to the Wisconsin Birth Defects Prevention & Surveillance System. 3. Provide data that is timely and accurate. 4. Use the Wisconsin Birth Defects Prevention & Surveillance System to access information and generate reports only as necessary to assist in providing services for clients and their families and to accurately report to the Wisconsin Birth Defects Prevention & Surveillance System. 5. Carefully and deliberately safeguard my user ID and password for the Wisconsin Birth Defects Prevention & Surveillance System in accordance with generally accepted security practices and my facility's policies and procedures. 6. Allow DHS staff and assigned agents to audit my Wisconsin Birth Defects Prevention & Surveillance System transactions to ensure compliance with the Wisconsin Birth Defects Prevention & Surveillance System Security and Confidentiality Policy. 7. Promptly report to the Wisconsin Birth Defects Prevention & Surveillance System any threat to or violation of the Wisconsin Birth Defects Prevention & Surveillance System security and Confidentiality Policy. By signing this form, I agree not to: 1. Furnish identifying information or documentation obtained from the Wisconsin Birth Defects Prevention & Surveillance System to individuals for personal use nor to any individuals who have no duties relating to birth defects screening, evaluation, service provision, or the general health of clients. 2. Copy the database or software used to access the Wisconsin Birth Defects Prevention & Surveillance System database. 3. Knowingly falsify any document or data obtained through the Wisconsin Birth Defects Prevention & Surveillance System. I have read, understand, and agree to abide by the Wisconsin Birth Defects Prevention & Surveillance System Security and Confidentiality Policy and the above requirements. I understand that, if I violate the Wisconsin Birth Defects Prevention & Surveillance System confidentiality requirements, my access to the Wisconsin Birth Defects Prevention & Surveillance System data can be terminated and I may be subject to penalties imposed by law.

________________________________________________________________ SIGNATURE ­ User ________________________________________________________________ Print Title of User

_________________ Date Signed _________________ Telephone Number