Request for Web Access

Request for Web Access

Use this form to request access for data entry and to view results from PhysLab
Full Legal Name*

First NameLast Name
Professional Suffix
Client Account Number*
Client Account Name*
Phone Number*
Email*

Confirmation Emailexample@example.com
Additional Information / Special Instructions

As a remote access user with privileges at PLS/PLPC, you may have access to what this agreement refers to as "confidential information." The purpose of this agreement is to help you understand your duty regarding confidential information. Confidential information includes PHI (protected health information). You will have access to confidential information through our computer system.

Confidential information is valuable and sensitive and is protected by law and by strict PLS/PLPC policies. The intent of these laws and policies is to assure that confidential information will remain confidential - that is, that it will be used only as necessary to accomplish the organization's mission. As a remote access user, you are required to conduct yourself in strict conformance to applicable laws and PLS/PLPC’S policies governing confidential information. Your principal obligations in this area are explained below. You are required to read and to abide by these duties. The violation of any of these duties will subject you to legal liability. As a remote access user, you understand that you will have access to confidential information, which may include information relating to patients’ – PHI (Protected Health Information) such as patient results and demographic information.

Accordingly, as a condition of and in consideration of your access to confidential information, you promise that:

1. You will use confidential information only as needed (minimum necessary) to perform your legitimate duties as a remote access user, affiliated with PLS/PLPC. This means, among other things, that:
a. You will only access confidential information for which you have a need to know; and
b. You will not in any way divulge, copy, release, sell, loan, review, alter or destroy any confidential information except as properly authorized within the scope of your professional activities affiliated with PLS/PLPC; and
c. You will not misuse confidential information or carelessly care for confidential information.

2. You will safeguard and will not disclose your access code or any other authorization you have that allows you to access confidential information.

3. You accept responsibility for all activities undertaken using your access code and other authorization.

4. You will report activities by any individual or entity that you suspect may compromise the confidentiality of confidential information. Reports made in good faith about suspect activities will be held in confidence to the extent permitted by law, including the name of the individual reporting the activities.

5. You understand that your obligations under this Agreement will continue after termination of your relationship with Physicians Laboratory. You understand that your privileges hereunder are subject to periodic review, revision and if appropriate, renewal.

6. You understand that you have no right or ownership interest in any confidential information referred to in this Agreement. PLS/PLPC may at any time revoke your access code, other authorization, or access to confidential information. At all times, you will safeguard and retain the confidentiality of all confidential information.

7. You will be responsible for your misuse or wrongful disclosure of confidential information and for your failure to safeguard your access code or other authorization access to confidential information. You understand that your failure to comply with this Agreement may subject you to legal liability both civil and criminal.
Client Agreement*

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