Healthcare Cerner Direct Account Form

HEALTHCARE CERNER DIRECT ACCOUNT FORM

Use this form to request a Cerner Direct secure messaging account for the exchange of protected health information (PHI). Completion of this form and acceptance of the terms below is required prior to issuance of a Direct address. The applicant certifies that the information provided is accurate and that account privileges will be used only for legitimate treatment, payment, and health care operations consistent with applicable law and organizational policy.

Applicant Information

Requested Account Details

Requested Direct Address (local part):

Supervisor / Manager Authorization

Security, Privacy and Use Acknowledgements

By signing this form the applicant acknowledges and agrees to the following mandatory terms:

1. Account holders will use Cerner Direct only for authorized exchange of PHI and only in accordance with all applicable federal and state privacy laws and organizational policies.
2. Credentials and access are strictly individual. Sharing of usernames, passwords, tokens, or two-factor devices is prohibited.
3. The account holder must implement appropriate safeguards for PHI transmitted or received and must report any suspected compromise or unauthorized disclosure immediately to the organization’s privacy/security office.
4. The organization may monitor, audit, suspend, or revoke Direct access for cause, including misuse, unauthorized disclosure, or noncompliance with policy.
5. Transmitted content may be subject to retention, discovery, and disclosure under applicable law; the account holder must avoid transmitting unnecessary or excessive PHI.

Identity Verification

Audit, Suspension and Revocation

The organization reserves the right to audit use of Cerner Direct accounts and to suspend or revoke access for reasons including, but not limited to: unauthorized use, suspected account compromise, repeated policy violations, or change in employment status. The account holder must cooperate with security investigations and corrective actions.

Optional Delegate / Proxy Access

If a delegate is requested to send or receive messages on behalf of the applicant, provide delegate details below and describe scope of delegation.

Certification and Signature

I certify under penalty of organizational disciplinary action that the information in this request is true and complete. I accept responsibility for safeguarding my access credentials and for all activity performed using my account. I understand that misuse may result in disciplinary action up to and including termination and civil or criminal penalties where applicable.

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