Facility User Account Agreement

Facility User Account Agreement

Please print clearly

Section 1: Internet Data Submission (IDS) User Account Information (all information is required)

1. FACILITY NAME:

2. AHCA NUMBER:

3. NAME OF IDS USERS (FIRST, MIDDLE INITIAL, LAST):

A. USER 01:

B. USER 02:

C. USER 03:

D. USER 04:

I understand that as an IDS User, I can submit data and retrieve the status of the data on behalf of the above designated facility.

I understand that by signing this document I am authorizing the Agency to send users of this system emails from time to time as it deems necessary.

By signing this document I acknowledge reading, understanding, and agreeing to its contents.

I understand that as an appointed User Account Administrator on behalf of the facility, I have the responsibility to:

1. Create/add and delete user accounts for other IDS users within my facility. Creating a user account grants access for an individual to read, submit and correct my facility’s confidential data. Deleting user accounts revokes this access.

2. Modify the demographic information for my facility’s Primary, Secondary and Administrator Contacts. This will be the method that SCHS is notified of any changes in name, mailing address, phone number, and e-mail address for each contact. Modifying contact demographic information directly changes the information on the SCHS database.

3. Reset passwords for IDS users within my facility. In the event that a user misplaces or forgets their password, they will be directed to contact their User Account Administrator to have it reset. The User Account Administrator should authenticate the user prior to resetting the password and issuing a new password.

4. Unlock IDS user accounts. IDS will lock user accounts after three (3) unsuccessful log on attempts. When the account is locked, users will be required to contact their User Account Administrator to unlock their account.

8. USER SIGNATURES:

B. USER 02:

C. USER 03:

D. USER 04:

The original of this completed form, for each user at a reporting facility having IDS on-line access, shall be provided to SCHS at the time it is prepared and signed.

Section 2: For SCHS use only

Please Note: The Facility Administrator or Primary Contact at each facility must complete and sign the Third Party Authorization Agreement form approving a Designated Agent if a third party will be submitting this data to AHCA on behalf of the reporting entity.

Facility User Account Agreement Instructions and Definitions

Make a copy of the completed forms for your records. Mail the original(s) to:

AHCA, Attn: Data Collection and Quality Assurance Unit,
2727 Mahan Drive, Bldg. 3 MS#16
Tallahassee, FL 32308

SECTION 1: IDS Designated Agent User Information (All fields must be completed) --

To be completed by IDS User requesting access to Internet Data Submission System.

1. Facility Name: Provide the name of the reporting entity or facility.

2. AHCA number: Enter the identification number of the ambulatory center/hospital as assigned by AHCA for reporting purposes.

3. Name of IDS User: Provide the full name of the IDS user.

4. Business Address (Mailing Address): Enter the business address where you can receive mail.

5. E-mail address: Provide an e-mail address where you can be contacted.

6. Business Phone: Provide a phone number where you can be contacted.

7. Business Fax: Provide a fax number where you can receive faxes.

8. User Signature and Date: If you understand and agree with the responsibilities and guidelines for maintaining IDS security, as detailed in the user agreement, provide your signature and the date this agreement was signed.

SECTION 2: SCHS Use Only

Florida Center for Health Information and Policy Analysis 1/18/2007