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Web Portal User Request
User Information
Name
*
First Name
*
Last Name
*
Direct Phone
*
Email
*
For compliance and authentication, the e-mail address provided must be unique to the user requesting access.
Job Title
*
Provider (MD, DO, NP, PA, etc)
Nurse/MA
Scheduler/Referral Coordinator
Front Desk/Medical Records
Other Admin
Other Clinical
NPI
*
Provider Name
*
For verification purposes, please provide the name of one provider within your practice
Provider NPI
*
For verification purposes, please provide the NPI Number for one provider within your practice
Practice Name
*
Practice Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Practice Phone
*
Practice Fax
*
Does this practice have multiple locations?
*
Yes
No
Practice Manager/Administrator Name
*
First Name
*
Last Name
*
Practice Liaison
*
Jessica Murray
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Terms & Conditions
Outpatient Imaging Affiliates’ (OIA) portal offers immediate access to patients’ diagnostic imaging procedures and reports. It also provides details about scheduling status, completion of exam and the opportunity to enter diagnostic imaging orders. This portal contain patients’ protected health information; therefore, federal and state laws require that OIA and the treating clinician take appropriate steps to protect against the unauthorized use and disclosure of such information. The Health Insurance Portability and Accountability Act ("HIPAA") allows health information concerning individual patients to be disclosed to another health care provider for purposes relating to the medical treatment of the patient. Providers are required by HIPAA to safeguard this information. To assure this protection of patients’ protected health information from unauthorized use or disclosure, you agree to the following conditions: Agreement Regarding your use of and participation in the Web Portal, you hereby agree to use protected health information accessed from using this web portal for the purpose of diagnosis and / or treatment of your patient(s), and for no other purpose except those permitted or required by applicable federal and state law. In addition, you agree to the following: * Use appropriate safeguards to prevent the use or disclosure of patient information other than as permitted pursuant to this agreement or applicable federal and state law; * Make certain that your employees or other agents who you authorize to access these portals comply with the provisions of this agreement and applicable federal and state law; * Ensure that each individual obtain and utilize a unique user name and password and to protect this information to prevent the unauthorized use or disclosure of those patient data; * Notify the OIA Service Desk when any authorized user of your organization is no longer in your employ / practice. * Report to the OIA HIPAA Privacy Officer any use or disclosure of protected health information not permitted by this agreement or applicable federal and state law. OIA reserves the right to terminate this agreement and your access to our web portals upon making a determination there has been a violation or breach of any of the terms and conditions of this agreement.
By clicking yes, I agree to the Terms & Conditions above
*
Yes
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