Provider Portal Account Request Form

Provider Portal Health Information Sharing Agreement

In order to set up a Provider Portal account, providers are required to read and accept the Health Information Sharing Agreement below. Please read the entire agreement and click the link at the bottom of the page to accept the terms of the agreement. Once you have accepted the terms, you will be directed to the account sign up form.

This Health Information Sharing Agreement (the “Agreement”) is entered into as of the date set forth below by and between Central California Alliance for Health, a local public agency (“the Alliance”), and the health care provider whose signature appears below (the “Provider”).

The Alliance operates a health plan through which it obtains health information concerning its enrollees and other persons. In order to improve the quality of care in the community, the Alliance operates a Virtual Clinical Network through which it makes this information available in electronic form to health care providers for use in treating individuals. The Alliance also offers or plans to offer other on-line services to assist providers in providing care or obtaining payment for care, including its eEligibility, eRAF, eTAR, eClaims Status, and eClaims Submission services. All the Alliance’s on-line services, whether offered now or in the future, are hereinafter referred to as “Online Services.”

The Provider is a health care provider, practitioner or supplier who desires to have access to the Online Services in connection with the provision of health care-related items or services to individuals. Provider is a covered entity and is therefore bound to comply with the Health Insurance Portability and Accountability Act (“HIPAA”) and the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”). In consideration of the Alliance’s permitting the Provider access to and use of the Online Services, the Provider represents and agrees as follows:

1. Qualifications: The Provider affirms that it is, and at all times during the term of this Agreement shall remain, a provider of health care services or a supplier of duly prescribed health care-related drugs, devices, equipment or other items (collectively, “Health Care”), and is duly licensed or certified as required by law. The Provider shall immediately notify the Alliance in writing if it ceases to meet the terms of this section.

2. Use of the Online Services by Provider: The Provider may use the Online Services only: (a) to provide Health Care to individuals in accordance with the scope of the Provider’s license (if any), and all applicable laws and regulations governing the provision of Health Care by Provider, and (b) to obtain payment for Health Care. The Provider must limit his or her access to and use of health information within the Online Services to the minimum necessary for these purposes. The Provider shall use all appropriate safeguards to prevent the use or disclosure of Protected Health Information (PHI) other than as permitted or required by Law. The Alliance may limit Provider’s access to the Online Services based on the nature of the services that Provider furnishes.

3. Use of the Online Services by Others: The Provider may permit its workforce (employees and others subject to Provider’s supervision and control) to have access to the Online Services for the purposes set forth in section 2. The Provider must obtain a unique identifier from the Alliance for each such person. The Provider shall notify the Alliance in writing within 48 hours of the termination of such person’s position as a member of Provider’s workforce, or of any change in such person’s duties that makes it unnecessary for him or her to have access to the Online Services.

4. Configuration: The Provider and its workforce may access the Online Services only in the manner authorized by the Alliance, and may not attempt to alter or reconfigure their access rights or methods of access. The Provider shall procure and use such computer hardware and software, and shall implement such security features, as the Alliance may require, to ensure the security of the Online Services. The Provider must immediately notify the Alliance if Provider changes its Internet Services Provider (ISP), or if the IP address assigned by Provider’s ISP changes.

5. Provider’s Policies and Procedures: The Provider must adopt appropriate physical, technical and administrative safeguards to implement its obligations under this Agreement, including restricting access to and use of the Online Services, assuring proper password management, and implementing appropriate personnel termination procedures.

6. Notification: The Provider shall immediately notify the Alliance of any violation of this Agreement, any threat to the confidentiality or security of the Online Services of which the Provider becomes aware, or in the event of any unauthorized viewing or disclosure of member PHI.

7. The Alliance’s Policies and Procedures: Provider shall comply with all policies and procedures furnished in writing from time to time by the Alliance to the provider concerning the use of Online Services.

8. Term and Termination: This Agreement shall continue until terminated by either party on thirty (30) days’ written notice to the other. The Alliance may terminate this Agreement immediately on notice to the Provider if the Alliance determines that the Provider has violated any terms of this Agreement, or if the Alliance determines that the continuation of the Agreement poses a threat to the security of the Online Services. Upon termination of this Agreement, the Alliance may terminate the Provider’s access to the Online Services.

9. Miscellaneous Provisions

a. Indemnification: Provider shall indemnify and defend the Alliance and its officers and employees from and against any claim, liability or cost (including reasonable attorneys’ fees) arising out of the breach of this Agreement by Provider, or any wrongful act or omission of Provider or a member of Provider’s workforce.

b. Limitation of Liability. Provider agrees that its sole remedy for any violation or breach of this Agreement by the Alliance shall be termination pursuant to section 8. UNDER NO CIRCUMSTANCES (INCLUDING BREACH OF THIS AGREEMENT) SHALL the Alliance BE LIABLE TO PROVIDER FOR MONETARY DAMAGES OF ANY KIND, OR FOR ANY OBLIGATION OF INDEMNIFICATION OR CONTRIBUTION.

c. No third-party beneficiaries. There are no third-party beneficiaries of this Agreement.

d. Entire Agreement; This Agreement, including all applicable Alliance Policies and Procedures constitutes the entire agreement of the parties relating to its subject matter, and supersedes all prior agreements and representations. Except as provided herein, no amendments or modifications to this Agreement shall be valid unless made in writing and signed by both the Provider and the Alliance.

i. Legally Required Modifications. The Alliance may amend this Agreement as necessary to comply with applicable laws and regulations. The Alliance shall provide at least 30 days’ written notice of such legally required modifications to Provider and such amendment shall become effective upon the expiration of the 30-day notice period, unless the Agreement is terminated by Provider prior to the expiration of the 30-day notice period, pursuant to section.

e. Notices. Notices shall be deemed delivered when delivered personally in writing, or three (3) business days after deposit in the United States Mail, first class postage prepaid, and addressed to the parties at their addresses set forth below; provided that a party may change its address for notices by giving notice to the other parties as provided in this section.