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HCA MOUNTAIN DIVISION IT&S SECURITY ACCESS REQUEST FORM 2025

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The document is an IT&S Security Access Request Form for non-privileged providers and office staff at HCA Mountain Division. It requires personal and practice information, emphasizes the importance of signing a Confidentiality and Security Agreement, and outlines responsibilities regarding the handling of confidential patient and company information. The agreement includes guidelines on accessing, using, and protecting confidential information, as well as consequences for violations.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Practice Information' section. Enter the practice/company name, address, and business phone number. Ensure all fields are completed accurately.
Next, provide details for the Office Manager and Office IT&S contact, including their full names and email addresses.
In the 'Personal Information' section, input your name, professional title, home address, date of birth, personal cell number, email address, and NPI number if applicable.
Select the access requests you need by checking the appropriate boxes under 'Fax request for access to'.
Review the Confidentiality and Security Agreement on pages 2-3. Ensure you understand its terms before signing at the end of the document.

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