IS Authorization Agreement - Palmdale Regional Medical Center 2025

1. Click ‘Get Form’ to open the IS Authorization Agreement in our editor.
2. Begin by filling out the Facility Information section. Enter the facility name, help desk contact, fax number, and email address as indicated.
3. In the Account Information section, provide the date, business name, office phone number, and contact details for two office representatives. Ensure all fields are completed accurately.
4. List all Authorized Users who will need access to private health information. Include their names, titles, and types (e.g., Physician or Office Personnel).
5. For external access requests, complete the Environment Specifications section detailing how many computers will access data and what type of devices will be used.
6. Specify the Reason for Request by checking relevant boxes and providing any additional details required.
7. Complete the Facility Authorization section with a signature from the CEO or Managing Director to finalize the agreement.

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