IMI PACS Access Request

Important Note:

Use this form to request access to IMI PACS only.

Thank you.
Applicant Information

* All Fields Must Be Complete
Name Name First Last
Phone Number: Phone Number: - ### - ### ####
Email Address:

Employer Provided Email Address - ALL REQUESTS WITH PERSONAL EMAIL ADDRESSES SUCH AS @GMAIL.COM WILL BE IMMEDIATELY DISCARDED
Last 4 Digits SSN - For Identity verification
Job Title
Employer:
Employer Address Employer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
I am requesting access to studies performed at:

(At least one...please be specific)
Requester Authorization: (note) this field is required to be filled out with the identity of someone other than the requester who is able to vet the authenticity of the original request.

I am a physician, manager or supervisor of the above-named requester and I am authorized to approve this request and do hereby approve it.
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Full Name

Authorized Signature
Authorized Name:
Authorized Title:
Contact Phone: Contact Phone: - ### - ### ####
Date Date / MM / DD YYYY
Terms Of Use Agreement

NOTICE: This is a binding contract. Failure to comply with the terms of this contract could result in your termination of employment and personal liability.

INTRODUCTION:
This agreement explains how you, as agent or employee of the entity identified on the first page above (“Entity”) may use RAPC’s System, the software underlying RAPC’s System, and patient data and information stored on or accessed through RAPC’s System.
Radiology Associates, P.C. (“RAPC”) owns and operates a picture archive and communication system (“RAPC’s System”). RAPC’s System includes hardware and software owned or licensed by RAPC (referred to as the “Hardware” and “Software” respectively). The Hardware and Software are subject to license agreements with third parties, copyright law, patent law, and trade secret law.
RAPC and Entity have signed a PACS Storage and Access Agreement (the “PACS Agreement”) setting forth the terms and conditions under which RAPC has agreed to allow Entity and its authorized users to use RAPC’s System to store and access information. One requirement of the PACS Agreement is that each individual user must sign an agreement setting forth the terms of use of RAPC’s System before becoming authorized to use RAPC’s System. This agreement fulfills that requirement. Accordingly, you will only be authorized to use RAPC’s System if you sign this agreement.
Note that the terms of this agreement (the “Terms”) supplement the PACS Agreement and are to be interpreted consistently with the PACS Agreement. To the extent that the Terms, or any of them, are inconsistent with the PACS Agreement, the PACS Agreement shall control.

AGREEMENT:

By signing below, I understand and agree to all of the following:

General Requirements:

I agree to handle all information obtained through RAPC’s System with utmost confidentiality. I understand that RAPC is granting me access to RAPC’s System solely for use in the course and scope of my services for Entity, and I agree to use RAPC’s System only in the course and scope of my services for Entity. I understand that RAPC will assign me a unique sign-on code and password (collectively “User IDs”), as well as Access Privileges, for the sole purpose of allowing me to use RAPC’s System. I understand that RAPC or Entity may revoke my right to use RAPC’s System at any time for any reason or no reason. I understand that any negligent or intentional violation of this agreement or breach of patient confidentiality by me with respect to information stored on or accessed through RAPC’s System will be cause for liability to RAPC and/or Entity, possible disciplinary action against me by Entity (up to and including termination of employment), and immediate termination of all my privileges to use RAPC’s System. I agree to comply with the PACS Agreement and not to engage in any conduct that would cause Entity to be in violation of the PACS Agreement. I understand that information stored on or accessed through RAPC’s System is subject to state and federal confidentiality and privacy laws, including but not limited to the privacy and security provisions of the Health Insurance Portability and Accountability Act of 1996 and regulations adopted thereunder (collectively “HIPAA”).

Password/Sign-on Code Terms of Use:

- I agree not to leave my workstation unattended while connected to RAPC’s System.
- I agree to use only my own User IDs to access RAPC’s System.
- I agree to keep my User IDs confidential and I will not let anyone else use them.
- I agree to notify Entity immediately if I think someone else has used or knows my User IDs.
Data/Patient Information:

- I have been trained in, understand, and will comply with the applicable provisions of HIPAA, Entity’s HIPAA privacy and security policies and procedures, and state confidentiality laws.
- I will not access a person’s information on or through RAPC’s System unless that person is Entity’s patient.
- I will only store and access information on or through RAPC’s System as allowed by law and the PACS Agreement.
- If I think anyone has used RAPC’s System improperly, I will notify Entity immediately.
- I will not share information stored on or accessed through RAPC’s System with any person, office or business except on a “need to know” basis and in compliance with HIPAA and state confidentiality laws.
- I will not store information on RAPC’s System that I know to be inaccurate.

Software and Hardware Terms of Use:

- I will not reverse reengineer, reverse assemble, reverse compile or otherwise attempt to discover the source code of any Software or part thereof.
- I will not use the Software or RAPC’s System for any timesharing or service bureau purposes or for any purposes other than those set forth in the PACS Agreement, nor will I sell, rent, sublicense, or otherwise share my rights to use the Software or RAPC’s System.
- I will not modify, adapt, translate, or create derivative works of the Software or the Software documentation.
- I will not disclose or disseminate the Software to anyone not authorized to receive it.
- I will not violate the terms of any software license agreement or laws applicable to the Software.
- I will not connect or install unauthorized equipment, hardware or software onto RAPC’s System or use them to access RAPC’s System.
- I will not knowingly introduce any virus or malicious code onto RAPC’s System.
- I will not copy Software or Software documentation without specific authorization.
- I will cease using RAPC’s System immediately upon termination of employment and upon notice I am no longer authorized to do so, and I will promptly return all copies of Software and Software documentation in my possession or control at that time.

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Name: Name: First Last
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Date Date / MM / DD YYYY

IMI PACS Access Request

IMI PACS Access Request

Important Note:

Applicant Information

Requester Authorization: (note) this field is required to be filled out with the identity of someone other than the requester who is able to vet the authenticity of the original request.