Request A link Account

To request Link access please complete this form, in its entirety, and agree to the terms in the Electronic Health Record Access Agreement. A U of U Health representative will contact you with the next steps.

If you have difficulties completing this form please contact Link Support at 801-587- 7322.

Clinic or Practice Information

Clinic or Practice Name ^*

Practice NPI (National Provider Identifier) if Applicable

Contact Name ^*

Contact Phone Number ^*

Clinic or Practice Address

Address

City/Town

State/Province

ZIP/Postal Code

Provider Information

Provider Name

First ^*

Middle

Last ^*

Phone Number

Email Address

Date of Birth

NPI (National Provider Identifier) ^*

Electronic Health Record Access Agreement

Purpose of Agreement. As a condition to your access to certain Confidential Information obtained and maintained by University, you agree to the terms set forth below. The terms of this Agreement are intended to ensure compliance with Federal and state laws and regulations, as well as University policies and procedures, which protect Confidential Information, assure that it remains confidential and permit it to be used for appropriate health care purposes.
Confidential Information. In this Agreement, “Confidential Information” means Protected Health Information obtained or maintained by University. “Protected Health Information” as that term is defined in HIPAA (as defined below), includes information that:
1. Identifies an individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual; and
2. Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
3. Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
Applicable Law. In this Agreement, “Applicable Law” refers to any Federal or state laws or regulations that apply to the protection or use of electronic health records, which includes, but is not limited to:
1. the Health Insurance Portability and Accountability Act, 45 C.F.R. §§160, 164, as amended (“HIPAA”); and
2. the Health Information Technology for Economic and Clinical Health Act, Division a, Title XIII of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, as amended (“HITECH Act”).

AGREEMENT

Responsibilities of Provider. To qualify as a Provider having access to Confidential Information, I agree to comply with all Applicable Law and University policies and procedures governing Confidential Information. By signing this Agreement, I agree to the following:
1. I will safeguard the privacy and security of Confidential Information;
2. I will comply with all security and privacy measures set forth in any Applicable Law;
3. I will limit my access and use of Confidential Information only to the minimum necessary to perform my University-approved responsibilities as a Provider;
4. I will not access or use Confidential Information that I have no legitimate need to access or use;
5. I will safeguard and will not disclose my access code or any other authorization that allows me to access Confidential Information. This means, among other things, that I will:
  1. Accept responsibility for all activities undertaken using my access code and other authorization;
  2. Report any reasonable suspicion or knowledge I have that my access code, authorization, or any Confidential Information has been misused or disclosed, either intentionally or unintentionally, without University’s authorization. (I will report such suspicions and knowledge to the University’s Information Security and Privacy Office at (801) 587-9241.); and
  3. Report activities by any individual or entity that I reasonably suspect may intentionally or unintentionally compromise the confidentiality of Confidential Information. (Reports made in good faith about suspicious individuals or activities, as well as the names of the reporters, will be held in confidence to the extent permitted by law.)
6. I will not misuse Confidential Information and will not disclose, copy, alter or destroy any Confidential Information except as properly authorized within the scope of my responsibilities as a Provider;
7. I will not access or use Confidential Information after the termination of my privilege to access Confidential Information;
8. I understand that University regularly audits its electronic health record system to determine, and ensure, any access or use is appropriate, and I will cooperate in any such audit by University;
9. Prior to any access or use of Confidential Information, I will sign the Confidentiality Agreement provided by the University and, at all times, abide by its terms; and
10. I will immediately notify the University if I am no longer actively licensed as a physician in the State of Utah.
Violations by Provider. I agree that:
1. I am responsible for my noncompliance with this Agreement;
2. If I violate any provision of this Agreement, I will be subject to disciplinary action and the University may, among other things:
  1. terminate my ability to access Confidential Information;
  2. report the violation to my employer and the Utah Division of Occupational and Professional Licensing; and
  3. pursue legal remedies against me;
3. If I violate any provision of this Agreement, I will reimburse the University for all expenses, losses or costs incurred in connection with investigating and reporting such violation and I will defend, indemnify and hold harmless University, its officers, employees and agents, from and against all liability, damages, judgments, expenses, losses or costs incurred, including reasonable attorneys’ fees, arising from such violation;
4. Any violation of this Agreement will harm University and others in ways that cannot be compensated adequately by money. And because of that harm, I agree that University will be entitled to a court order prohibiting my use of Confidential Information except as permitted by this Agreement; and
5. University may also terminate my access to Confidential Information if my status as a Provider changes.
Miscellaneous.
1. Term. This Agreement shall remain in effect so long as Provider is actively licensed as a physician in the State of Utah. University, however, may terminate this Agreement at any time, with or without cause, and any provisions that by their nature should survive termination shall survive and remain in effect.
2. Governing Law. This Agreement shall be governed by the laws of the State of Utah, without regard to conflict of laws principles. Venue for any lawsuits, claims or other proceedings between the parties relating to or arising from the Agreement shall be exclusively in the County of Salt Lake.

I have read and AGREE to these terms and conditions.

Purpose of Agreement. As a condition to your access to certain Confidential Information obtained and maintained by University, you agree to the terms set forth below. The terms of this Agreement are intended to ensure compliance with Federal and state laws and regulations, as well as University policies and procedures, which protect Confidential Information, assure that it remains confidential and permit it to be used for appropriate health care purposes.
Confidential Information. In this Agreement, “Confidential Information” means Protected Health Information obtained or maintained by University. “Protected Health Information” as that term is defined in HIPAA (as defined below), includes information that:
1. Identifies an individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual; and
2. Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
3. Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
Applicable Law. In this Agreement, “Applicable Law” refers to any Federal or state laws or regulations that apply to the protection or use of electronic health records, which includes, but is not limited to:
1. the Health Insurance Portability and Accountability Act, 45 C.F.R. §§160, 164, as amended (“HIPAA”); and
2. the Health Information Technology for Economic and Clinical Health Act, Division a, Title XIII of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, as amended (“HITECH Act”).

AGREEMENT

Responsibilities of Provider. To qualify as a Provider having access to Confidential Information, I agree to comply with all Applicable Law and University policies and procedures governing Confidential Information. By signing this Agreement, I agree to the following:
1. I will safeguard the privacy and security of Confidential Information;
2. I will comply with all security and privacy measures set forth in any Applicable Law;
3. I will limit my access and use of Confidential Information only to the minimum necessary to perform my University-approved responsibilities as a Provider;
4. I will not access or use Confidential Information that I have no legitimate need to access or use;
5. I will safeguard and will not disclose my access code or any other authorization that allows me to access Confidential Information. This means, among other things, that I will:
  1. Accept responsibility for all activities undertaken using my access code and other authorization;
  2. Report any reasonable suspicion or knowledge I have that my access code, authorization, or any Confidential Information has been misused or disclosed, either intentionally or unintentionally, without University’s authorization. (I will report such suspicions and knowledge to the University’s Information Security and Privacy Office at (801) 587-9241.); and
  3. Report activities by any individual or entity that I reasonably suspect may intentionally or unintentionally compromise the confidentiality of Confidential Information. (Reports made in good faith about suspicious individuals or activities, as well as the names of the reporters, will be held in confidence to the extent permitted by law.)
6. I will not misuse Confidential Information and will not disclose, copy, alter or destroy any Confidential Information except as properly authorized within the scope of my responsibilities as a Provider;
7. I will not access or use Confidential Information after the termination of my privilege to access Confidential Information;
8. I understand that University regularly audits its electronic health record system to determine, and ensure, any access or use is appropriate, and I will cooperate in any such audit by University;
9. Prior to any access or use of Confidential Information, I will sign the Confidentiality Agreement provided by the University and, at all times, abide by its terms; and
10. I will immediately notify the University if I am no longer actively licensed as a physician in the State of Utah.
Violations by Provider. I agree that:
1. I am responsible for my noncompliance with this Agreement;
2. If I violate any provision of this Agreement, I will be subject to disciplinary action and the University may, among other things:
  1. terminate my ability to access Confidential Information;
  2. report the violation to my employer and the Utah Division of Occupational and Professional Licensing; and
  3. pursue legal remedies against me;
3. If I violate any provision of this Agreement, I will reimburse the University for all expenses, losses or costs incurred in connection with investigating and reporting such violation and I will defend, indemnify and hold harmless University, its officers, employees and agents, from and against all liability, damages, judgments, expenses, losses or costs incurred, including reasonable attorneys’ fees, arising from such violation;
4. Any violation of this Agreement will harm University and others in ways that cannot be compensated adequately by money. And because of that harm, I agree that University will be entitled to a court order prohibiting my use of Confidential Information except as permitted by this Agreement; and
5. University may also terminate my access to Confidential Information if my status as a Provider changes.
Miscellaneous.
1. Term. This Agreement shall remain in effect so long as Provider is actively licensed as a physician in the State of Utah. University, however, may terminate this Agreement at any time, with or without cause, and any provisions that by their nature should survive termination shall survive and remain in effect.
2. Governing Law. This Agreement shall be governed by the laws of the State of Utah, without regard to conflict of laws principles. Venue for any lawsuits, claims or other proceedings between the parties relating to or arising from the Agreement shall be exclusively in the County of Salt Lake.

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