ADVOCATE HEALTH CARE System Access Request Form
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FACULTY - CareConnection/Pharmacy-PYXIS
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Site: Advocate Condell Medical Center_
School: ________________________________________________________________________________________________________
Course Name/Number:____________________________________________________________________________________________
Faculty Name:_______________________________________________________ Cell Phone:________________________________
Office Phone: ____________________________________ Ext.: _____________ Pager: ______________________________________
Email: ___________________________________________ Second: ______________________________________________________
License Number: ___________________________________ Expiration Date:_________________________ Type: RN APN PT Other
If “Other” Please list _____________________________________________________________________________________________
PLEASE READ THE FOLLOWING STATEMENT AND SIGN AT THE Faculty Signature LINE TO VERIFY THAT YOU
HAVE READ AND UNDERSTAND THE STATEMENT AND WILL ENTER A NEW, CONFIDENTIAL PASSWORD.
Confidentiality Agreement:
As a non-employee of Advocate Health Care, you or your representatives may have access to patient, medical record, employee or other confidential information. As a condition to being granted such access,
you are required to agree to the following:
I understand that in the course of my working relationship with Advocate Health Care, I share the responsibility of maintaining the confidentiality of any patient, medical record or employee information that I
may have available to me. I understand that it is my responsibility to follow Advocate Health Care policies and procedures as they relate to the assurance of patient rights and the confidentiality of information
both written and verbal.
Computer Systems: I understand that I may receive a unique User-Id and a personal password necessary for me to gain access to an Advocate Health Care computerized system. I understand and agree that
both the User-id and my Password are for my own personal use and are not to be disclosed to or used by third parties. If at any time I feel that the confidentiality of my User-id or password has been
compromised, I will contact appropriate management (Advocate employee that approved your access) for direction within 24 hours.
Conduct and Confidentiality: I understand that I must maintain the confidentiality of any written or oral patient, medical record or employee information that I have access to or view as a result of my working
relationship with Advocate Health Care. I understand that the release of patient, medical record or employee information of any kind is only allowed by Advocate Health Care policy guidelines. If I am
uncertain or do not understand the Advocate Health Care policy guidelines, I will contact the appropriate Advocate manager (Advocate employee that approved your access) for assistance and direction within
24 hours. I agree to only release patient, medical record or employee information under the Advocate Health Care policy guidelines or as required by law.
Patient, Medical Records and Employee Information: I acknowledge that all information involving patients, medical records and employee information is private and confidential. I agree that I shall access
only that data necessary for the proper performance of my job responsibilities under my business relationship with Advocate Health Care. I further agree to keep confidential any and all information that I
access, receive or transcribe, and not to disclose any such information to third parties. I am aware, that, unless specifically identified as part of my job by “Advocate Health Care”, I am not authorized to discuss
any information concerning a patient’s or employee’s personal data or medical condition. I am responsible for ensuring that discussions regarding patient, medical record and employee information are held in
appropriate locations with only authorized individuals.
Any unauthorized disclosure on my part or my representatives will be a very serious offense to Advocate Health Care. Such unauthorized disclosure may result in Advocate’s repossession of all of my or my
representative’s access to patient, medical record and employee information, Advocate may also act up to and including termination of my business relationship with Advocate and asserting its full rights under
the law.
Pyxis: I will access the system and will change the initial password to a new confidential Password. I understand that in combination with my User ID code, this will be my electronic signature for all
transactions to the Pyxis System. I understand that no retrievable record of my new password will exist. All transactions will be permanently recorded with my User ID and a date and time-stamp. These
records will be maintained and archived as per the policies.
I understand that to maintain the integrity of my electronic signature, I must not give this password to any other individual.
Faculty Printed Name (Last, First)
Faculty Signature
Date
Last Four Digits of SSN: ___ ___ ___ ___ AdvocateOne ID (If applicable): _____________________
Access Required: Unit: __________________Start Date: __________________ End Date: _______________________
( Account will be created ASAP if no date )
( Account will expire in one month from the time received if no End date )
Access Type: CareConnection: position/role “Nursing Instructor” PYXIS for Pharmacy
*Do you require access to psychiatric (confidential) units? YES NO
If yes, please explain: __________________________________________________________________________________________
Authorized by:
(Please make sure all of the above are correct) (Upon receipt please allow 3 to 4 business days to complete this request)
Print Name: _Danene Coroneos-Shannon__________________________________ Cost Center: ___3030________________
Title/Dept: _System Clinical Development Specialist/Clinical Education_ Phone #: (630) 929-6283___________________
_______________________________________________________ Date: _________________________________________
(**Authorized by Signature**)
Fax to 630-575-8153 c/o IS Security & COND-IS-
Acce[email protected]m c/o Pharmacy or forward this request to: IS Security Administration, AHC Support
Center, 1400 Kensington Rd., Oak Brook IL 60523
( For Information Systems Security Administration Use Only )
Completed by: ______________________________________________________ Date: __________________________
Feb 2018 ~ Confidential ~ CareConnection
