Free 53763.pdf - Indiana

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Physician / Coroner / Health Officer IDRS Confidentiality Agreement
The Indiana Death Registration System (IDRS) is implemented by the Indiana State Department of Health under the authority of Indiana Code: IC 16-37-1. All information in the system is confidential, and all users have a responsibility to abide by confidentiality laws. Users who violate these laws will have access to the IDRS immediately revoked by the State Registrar. · · · · All users shall safeguard his/her user ID , password and PIN number, and agree to not give a user ID, password and/or PIN number to others, or to post a user ID, password and PIN number on any place. Individual IDRS passwords should be changed periodically to protect security. The system will prompt for a password change. The computer should not be left unattended when an IDRS session is open. Always log off when you are finished with an IDRS session.

By signing this form, the User acknowledges the conditions under which access to the IDRS is granted, and agrees to be held to these conditions. Facility Name: __________________________________________________________________ ______________________________________________________________________________ Print Employee Name Date (month, day, year) Employee Signature Employee e-mail: ________________________________ Telephone: ___________________ State issued drivers license or state ID number: _____________________________________ ______________________________________________________________________________ Site Manager's Name Date (month, day, year) Site Manager's Signature Site Manager's e-mail: _____________________________ Telephone: ___________________ Assigned User ID (provided by ISDH): ____________________________________________ Send completed form and a photocopy of your state issued drivers license or state ID to: Vital Records Department Indiana State Department of Health 2 North Meridian Street Indianapolis, IN 46204 OR fax to the IDRS Support Center at 317-233-5956 Please copy additional sheets as necessary.

State Form 53763 (R2 / 5-09)

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Physician / Coroner / Health Officer
First Name: _______________________
Middle name: ______________________ Last Name: ________________________________ Suffix: ___________________________ Title: DO. MD.

License number: _________________________ Term Expires:__/__/____ Type: Physician Coroner Deputy Corner Health Officer

List all Locations Where you Certify Cause of Death To E-mail:____________________________________________________________________ CC E-mail: ___________________________________________________________________ (1) Office Association Name: _____________________________________________________ Address: ___________________________________________________ City: _____________________State: _____ ZIP: _______ Ext:_______ Telephone number: (_______) ___________________ (2) Office Association Name: _____________________________________________________ Address: ___________________________________________________ City: _____________________State: _____ ZIP: _______ Ext:_______ Telephone number: (_______) ___________________ (3) Office Association Name: _____________________________________________________ Address: ___________________________________________________ City: _____________________State: _____ ZIP: _______ Ext:_______ Telephone number: (_______) ___________________

(4) Office Association Name: _____________________________________________________
Address: ___________________________________________________ City: _____________________State: _____ ZIP: _______ Ext:_______ Telephone number: (_______) ___________________

State Form 53763 (R2 / 5-09)