PUBLIC HEALTH
INSURANCE MANAGEMENT SERVICES
KINNEY
Confidentiality Agreement
Service Providers
District: _________________________________________________________________
Name: ______________________________________Therapy:_____________________
E-mail Address: __________________________________________________________
License/Certification
Number: ______________________________________________
If not Licensed: Name
of Licensed Professional of the Healing Arts who provides direction for
Medicaid Services: ____________________________________________
I have received my user Identification (UserID) and Password and agree to the following:
Ø I will not share my UserID and Password.
Ø I will keep my UserID secure and password secure, i.e. not accessible to anyone else.
Ø If my UserID or Password is compromised or lost I will immediately notify District's KINNEY Access/Security Manager identified below and KINNEY by calling 1-518-371-0176 or emailing helpdesk@kinneyassoc.com.
Ø When entering services on the KINNEY web site I will assure that no one is able to observe. I will make sure that my monitor is not viewable by others and will sign off when I am finished entering information.
Ø When entering and/or accessing information on the KINNEY web site I will comply with all federal and state regulations controlling its treatment and release. This includes, but is not limited to the Family Education Rights to Privacy Act (FERPA) and the Health Insurance Portability and Accountability act of 1996 (HIPAA).
Ø I will immediately report to the District's KINNEY Access/Security Manager if the security/confidentiality of my password is compromised in any way.
Ø I accept full responsibility for the accuracy of the information I report.
By signing this document I am certifying that 1. I have read and understand all of the above terms of use and agree to them; 2. If licensed, I will report only services that I have personally provided; and 3. If not licensed, I will report only services that I have personally provided under the direction of a licensed professional.
Print
Name: ______________________________________
Signature:
________________________________________
Date: _________________
Name
of the District's Ksystems© Access/Security Manager:
Print
Name: ______________________________________
Signature:
________________________________________
Date: _________________