Request for Remote System Access for Texoma Medical Center

Please complete the following information for the person needing access.

Requested applications: *

User Information:

First Name: *

Middle Initial:

Last Name: *

Credentials:

Email Address:

Date Of Birth: * +

Cell Phone Number *

Does user currently have or has had access to TMC Systems? If yes, will user continue to need current access? *

Yes

No

Clinic or Company information:

Is there a BA agreement or a Health information Data Access Agreement on file? if no see link below for both forms *

Company or Clinic Name: *

Contact First Name *

Contact Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Submitted By: *

Access information will be sent to this address

Forms

Companies are required to have a valid Business Associate Agreement. Physician offices must have a completed Health Information Data Access Agreement. Each end user is required to complete and sign an Information Security and Privacy Agreement.

These forms are not needed if they are already on file.

Title of the document

Business Associate Agreement

Information Security and Privacy Agreement.

Health Information Data Access Agreement

Please send completed Business Associate Agreements, Information Security and Privacy Agreements and Health Information Data Access agreements if required to : TMCremoteaccess@thcs.org

Access is restricted to business use. If your login is used to access personal or family accounts that are not patients of that clinic/company, access may be revoked.

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