Cerner Login Request Form

University Health System, Inc.
Cerner Request Form

Form to be completed by supervisor/manager. For questions about this form for changes in existing accounts or forgotten passwords please call the Help Desk @ (865) 305-4357
Confidential Information Statements
All personnel applying for and accessing the Clinical Information System have an obligation and responsibility not to divulge or discuss any information pertaining to a hospital patient or confidential hospital business.

This is one of the fundamental ethics binding those who, either directly or indirectly care for the sick.

The user's sign-on and password are confidential. Only the individual is to know this information. All information on the University of Tennessee Medical Center network is confidential. Gaining access to such information, disclosing confidential information; or otherwise missing protected health information or data is prohibited.

Violation of any of these work rules may be cause for disciplinary action up to and including termination of employment.
By clicking I agree selection below, as manager/supervisor, I attest that I have personally reviewed the above confidential information statements with the below individual who agrees to comply with these statements.*

I agree
Date*

MonthDayYear
Applicant's Information:
Applicant's Name*

First NameMiddle NameLast Name
Applicant's Last 4 digits of Social Security Number:*
xxx-xxx-____
Applicant's Email*
individual's email address
Applicant's Phone Number*

Area CodePhone Number
Applicant's Job Title/Job Responsibility*
Is there a past of current coworker with the same kind of access needs?

YESNO
Please provide the name of a coworker who as the same kind of access that the applicant needs:

First NameLast Name
Department Information:
Department Name*
Department Location*
Information for Supervisor/Manager:
Supervisor's Name*

First NameLast Name
Supervisor's Email*
Supervisor's Phone Number*

Area CodePhone Number
UTMC Point of Contact/Liaison*

First NameLast Name
UTMC Point of Contact/Liaison Phone *

Area CodePhone Number
UTMC Point of Contact/Liaison Email*
liaison's email
What Cerner Applications are requested for this individual?*

PowerChartPerson ManagementRadNetFirstNetPowerChart AmbulatoryCPMOther
What tasks will this individual be performing in Cerner?*

View Financial Information OnlyPatient RegistrationPlacing OrdersView Results
Does this individual work for University Health Systems (UHS), University Physicians Association (UPA), Graduate School of Medicine (GSM), East TN Children's Hospital Lab Corp or LHC Group?*

YesNo
Choose the name of the company this individual works for:*

Team HealthThe WellFundUniversity Orthopaedic Surgeons (UOS)Tennessee Donor Services (TDS)University RadiologyWashington West, LLCOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
By clicking I agree selection below, as manager/supervisor, I attest that I have personally reviewed the below Confidentiality Pledge with the above individual who agrees to comply with these statements.*

I agree
I will be granted access to an electronic database maintained by University Health System, Inc. (“UHS”) containing certain confidential and proprietary information, including protected health information (“UHS PHI”) as defined under the Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act (“HIPAA"). I understand that Company has agreed to provide certain services to UHS and that my access and use of UHS PHI is related to provision of those services. I also understand that Company and UHS have entered into a Business Associate Agreement, which limits the rights of Company and its employees and contractors to use UHS PHI and requires Company and its employees and contractors to prevent the unauthorized use or disclosure of UHS PHI.

In consideration of my right to access and use UHS PHI and to protect the confidentiality of UHS PHI and prevent its unauthorized use or disclosure:

* I pledge and agree to limit my access and use of UHS PHI to those records that are necessary for me to perform the specific duties assigned to me by Company.

* I pledge and agree to hold any and all UHS PHI that I may come into contact with as an employee or contractor of Company absolutely and completely confidential.

* I pledge and agree not to use or disclose any UHS PHI, other than as stated in this Pledge or required by law.

* I understand that I will be granted access to UHS PHI for a period of six (6) months and that Company will need to request my continued access by faxing a request to 865-305-6968 no more than two (2) weeks in advance of the expiration the current six (6) month period.

* I understand that my access to UHS PHI will be terminated immediately if I:

* Disclose UHS PHI except as necessary to perform the specific duties assigned to me by Company;

* Access any UHS PHI that is not associated with the specific duties assigned to me by Company, including records of family, friends, or high profile/famous individuals.

* Download UHS PHI to an unencrypted storage device or system.

* Post UHS PHI on social media sites (e.g. Facebook, Instagram, Snap Chat, GoFundMe, Twitter, LinkedIn, YouTube, Vine, Flickr, Google+, or Digg).

* Leave UHS PHI unattended such as on a desk, computer monitor where anyone could view.

* Print UHS PHI and do not dispose of it properly by shredding; or

* Leave UHS PHI in printer, copier, scanner or a fax machine or other unsecure location.
Should be Empty:

University Health System, Inc.

Cerner Request Form