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NOTE: THIS FORM IS NOT TO BE USED TO GAIN ACCESS TO SUBMITTING ELECTRONIC REFERRALS

PHYSICIAN INFORMATION PORTAL ACCESS FORM

Physician Name
Address
City
 
Zip
Select Region/Area
 
Physician Telephone Number   
Fax Number
Practice / Group name
Select Request Type: (select all that apply)
Please do not print from browser:Upon completion, Click the "Print Portal Access Form" button and Print the PDF.
Physician / Staff Name Email Address Physician NPI Signature Username(HCP-Connect! Referrals only)

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Code 
Clearing
Cap 
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Audit 
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Deferments

Sign After Printing
Code 
Clearing
Cap 
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PatSat 
Report
Audit 
Report
Deferments

Sign After Printing
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Clearing
Cap 
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Audit 
Report
Deferments

Clinicians or designees understand that the use of Health Insurance Portability and Accountability Act (HIPAA) standards is intended to provide enhanced protections for individually identifiable health information. Clinicians or designees also understand they will be expected to comply with these standards and to use, protect, and disclose Protected Health Information (PHI) only in accordance with the scope of their duties. Unauthorized release or use of PHI will result in performance improvement action, up to and including termination of contract.
Clinicians or designees further understand that the HIPAA security regulations address PHI in electronic format, to include portable and desktop computers (both hardware & software) or any other device capable of receiving or transmitting PHI. Clinicians or designees assume responsibility for the security of the devices and confidentiality of the PHI within his/her scope of control. Clinicians or designees will take reasonable steps to mitigate incidental disclosures and report to the appropriate supervisor any unauthorized disclosure, or potential of disclosure, of protected health information (e.g. theft of laptop, unauthorized access or log in, etc.).
Clinicians or designees recognize that the unauthorized release of certain trade secret information is detrimental to the interests of HCP. Such information includes, but is not limited to, business strategies, technology and technical data, patient lists, contracts and information regarding contract negotiations, concepts, clinical research protocols, data, and agreements, materials, product design, formulae, marketing data and plans, financial data, and any intellectual property therein or related thereto. Trade secret information is a special, valuable and unique asset of HCP, therefore, clinicians and their designees are expected to safeguard all of HCP’s trade secrets, and the unauthorized release of any information therein or related thereto is strictly prohibited.
WHEN AN AUTHORIZED USER IS NO LONGER PART OF YOUR OFFICE PRACTICE, YOU WILL NEED TO UPDATE THE HCP CONNECT PHYSICIAN PORTAL ACCESS FORM WITH THE TERMINATION DATE AND YOUR INITIALS (OR YOUR DESIGNEE FROM THE PRACTICE), AND SUBMIT IT TO CSD SO THAT WE CAN TERMINATE THAT USER’S ACCESS.



Not to be used to request access to the electronic Referral Authorization System (HCP-Connect!)
Questions regarding this form can be directed to CSD at (310) 630-2300