My Quartz Tools Access Request Form

For Quartz Contracted Providers

My Quartz Tools Access for Providers

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Authorized Users

The following individual is Authorized to have site administrator account access. This individual is authorized to request access to be added, changed, or disabled for other individuals under the Facility Name. This account access will also allow the individual to have access to patient information. The site administrator is to be a business owner, manager, supervisor, team leader, or a person who has staff reporting to them.
If the Provider listed in this application (“Provider”) is granted access to My Quartz Tools the following conditions apply:

Access to My Quartz Tools shall not be construed as conferring any license to My Quartz Tools or any information contained in and / or displayed therein to Provider. Provider acknowledges and agrees that information contained in and / or displayed via My Quartz Tools may be considered Protected Health Information (“PHI”), as defined by the Health Insurance Portability and Accountability Act of 1996 (and regulations promulgated thereunder as amended from time to time) (“HIPAA”). As such, Provider agrees to abide by the Privacy and Security Rules of HIPAA and any other applicable laws and regulations.

Provider agrees to limit access to My Quartz Tools and information contained and / or displayed therein in accordance with HIPAA, which includes but is not limited to creating and assigning User IDs and passwords only for those end users who are authorized to use, access, or disclose PHI, and limiting use of PHI to the “minimum necessary” needed to complete work (“End User”). Under no circumstances should Provider or End User review PHI by accessing the medical record about self or family members.

Provider agrees to timely terminate access to My Quartz Tools when an End User resigns or changes job duties that no longer require the end user to access My Quartz Tools. Timely termination is termination within two (2) business days after one of the aforementioned events occurs. If there is a breach or suspected breach of a User ID or password, Provider and / or the End User must notify their Provider Coordinator as soon as practicably possible but no later than two (2) business days after discovery. Provider is responsible for any and all breaches of security resulting from End User access to My Quartz Tools.

Quartz reserves the right to terminate Provider’s and / or any End User associated with Provider’s access to My Quartz Tools at any time. The information contained within this form will be applied to all applicable contracts with Quartz Health Benefit Plans Corporation, Quartz Health Solutions, Inc., Quartz Health Plan Corporation, Quartz Health Plan MN Corporation, and Quartz Health Insurance Corporation.

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