IU Health Agreement for EMR/System Access or Badge Access 3rd Party Access for Non-IU Health UsersEmr/System Access Agreement • December 5th, 2023
Date Access to IU Health EMR/Systems is Requested: / / Date Access is to Expire (unless auto expiration*): / / *Access all to IU Health EMR/Systems will automatically expire for any of the following reasons:• January 1st each calendar/fiscal year (unless you have re-submitted this form for reprovisioning of access and annual HIPAA training completion by December 1st)• 90 days following non-use of your login credentials• Any time at the discretion of IU Health Reason for Requesting Access: Check all that apply:🞏 Treatment 🞏 Payment FN-1🞏x Education/Training 🞏 Research🞏 Business Associate performing services on behalf of IU Health involving Protected Health Information (PHI) (attach Business Associate Agreement, if available)🞏 Health Care OperationsFN-2 (Description required): If access for “Research”, then provide:Study Name(s): Protocol #(s): _ 🞏 Other (Please provide details as to the reason for requesting access) Research access: please provide one or more of the following i
