WFBI- Web Portal User Agreement

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*

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

State

ZIP Code

Practice Phone*

Practice Fax*

Does this practice have multiple locations? *

Yes No

Does this practice have additional providers?*

Yes No

Additional Providers*

Listing the providers here will allow their records to be accessible in the portal. Providers listed here will not automatically be issued portal logins. To obtain credentials they must submit an individual request .

Practice Manager/Administrator Name*

First Name

Last Name

Practice Liasion*

Please select your sales rep

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

Signature

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Use your mouse or finger to draw your signature above