KINNEY Therapist Confidentiality Agreement

 

District:_________________________________________________________________

Name:______________________________________License #____________________________ Expiration Date __/__/____

Title of Licensed/Certified Profession ________________________________Certification #_________________________ Expiration Date__/__/____

E-mail Address: __________________________________________________

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 "ksystems@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 Federal 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 will not knowingly report false information or knowingly permit the reporting of inaccurate information with regard to Medicaid Services.

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 which I have personally provided; and 3. if not licensed, I will report only services which I have personally provided under the direction of a licensed professional.

Print Name:______________________________________

Signature:________________________________________ Date:_________________

Signature of District's KINNEY Access/Security Manager:

________________________________________________ Date:_________________

 

 

User ID: ________________________ Password: ___________________