Fillable Irm-15 Form - Oasas printable pdf download

OASAS EXTERNAL USER ACCESS REQUEST

PART A – TO BE COMPLETED BY THE PERSON TO BE GIVEN ACCESS –

Please Print Clearly or Type To Avoid Delays in

Processing the Form. Accurate Logons are Dependent Upon the Clear Spelling of the User's Name.

1. NAME OF PERSON TO HAVE ACCESS

Last Name

First

Security Keyword (e.g. Mother’s Maiden Name, or other)

Work E-Mail Address

I understand that OASAS systems contain confidential data, use of which is restricted by and subject to the regulations of Title 42 of the Code of Federal

Regulations, 42 CFR Part 2, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 CFR Pts. 160 and 164; the Federal Driver’s

Privacy Protection Act (DPPA), 18 USC § 2721; and the NYS Information Security Breach and Notification Act, Chapter 442 and 491 of the Laws of

2005, codified in § 208 of the State Technology Law (STL) and § 899-aa of the General Business Law (GBL); I agree to comply with all requirements

set forth within the aforementioned sections of law governing the use and re-disclosure of information obtained through my access to OASAS systems;

I also agree that I will neither share my access code with any other person nor share with any unauthorized person information obtained from these

systems. My use of information obtained through OASAS systems is solely in accordance with my normal course of business and in connection with

the purpose for which my access to these systems has been approved. Misuse and abuse of information that is obtained from OASAS systems will

result in a termination of access and may subject me to civil and/or criminal penalties.

User

Telephone

Signature

No.

(

)

Date

2. AGENCY REQUESTING ACCESS (Select and Complete One Choice Only)

OASAS Provider No. (OASAS Certified Only)

Service Provider Name

LGU / County Name

3. ADDRESS (Street, City, State, Zip Code)

5. OPTIONS/LEVELS OF ACCESS

4. SYSTEM TO BE ACCESSED

(See Descriptions on Page 2)

Provider

LGU

Other

(Check only ONE OPTION below for any system access)

On-Line Reporting Options:

Client Management (CDS)

Inquiry

Data Entry or

File Transfer or

Inquiry

Workscope/Objective Attainment (WPR)

Data Entry or

Inquiry

Data Entry

Gambling

Data Entry or

Inquiry

Provider Directory System (PDS)

Data Entry

Data Entry or

Inquiry

Strengthening Treatment Access and

Inquiry

Retention – Quality Improvement (STAR-QI)

Program Number:

DMV Inquiry

Clinical Data Entry or

Clinical Inquiry or

Impaired Driver System (IDS)

IDP Data Entry

IDP Inquiry

Probation Inquiry

DMV Data Entry

Impaired Driver Classroom (IDC)

IDP Data Entry or

IDP Inquiry

DMV Inquiry

County Planning System (CPS)

Other

________________________

Data Entry or

Inquiry

Provider Help Desk

(specify)

PART B – TO BE COMPLETED BY THE AGENCY CONTACT PERSON AND SENT DIRECTLY TO OASAS AS INSTRUCTED ON PAGE 2

NAME OF AGENCY CONTACT PERSON (Print Last, First, MI)

Telephone No.

Fax No.

(

)

(

)

WORK E-MAIL ADDRESS

I hereby authorize the employee identified in Part A to obtain access to the system indicated in conjunction with his/her official duties. I will

contact OASAS immediately when the individual no longer requires such access.

____________________________________________________

_______

______

Signature

Date

FOR USE BY BUREAU OF INFORMATION TECHNOLOGY SERVICES

LOG-ON

USER NO.

SYSTEM ACCOUNT

APPLICATION ACCESS

USER NOTIFIED

ADDED

GRANTED

________

Initials

Date

Initials

Date

Initials

Date

ADDITIONAL COMMENTS/INSTRUCTIONS

REFER ANY QUESTIONS TO OASAS PROVIDER HELP DESK AT (518) 485-2379

IRM -15 (Rev 1/17)

Irm-15 Form - Oasas

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