Form Ims 01 PDF Details

Ensuring secure and appropriate access to systems is vital in managing information for individuals with developmental disabilities. The New York State Office for People With Developmental Disabilities provides a structured process through Form IMS-01, facilitating user ID and system access requests. This form is meticulously designed to cater to external users requiring access to specialized applications. It covers essential aspects such as user information, the request for OPWDD User ID and access, along with a critical statement of use, which enforces the responsibility and limitations tied to the granted access. The form also emphasizes the importance of executive approval, ensuring only authorized requests are processed, thereby safeguarding sensitive clinical information in line with Mental Hygiene Law Sec. 33.13, HIPAA, and OCS regulations. Completing the form with accuracy is paramount, as incomplete or incorrect details can lead to rejection, underlining the importance of adhering to the specified guidelines for a seamless process. This process not only underscores the regard for security and confidentiality but also aligns with legal compliance, demonstrating a comprehensive approach to manage access to sensitive systems and data.

QuestionAnswer
Form NameForm Ims 01
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesNYS, OCS, HIPAA, opwdd forms

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NYS Office for People With Developmental Disabilities

Form IMS-01 (Revised 01/28/2019)

User ID and System Access Request Form (External)

If unable to use Adobe Reader XI to complete form, please see page 2 for assistance.

Section 1 - User Information

DO NOT HANDWRITE IN SECTION 1

Agency Name:

First Name:

OPWDD Agency ID:

MI:

 

Last Name:

 

 

 

Title:

 

 

 

 

 

Work Telephone:

 

Work Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

City

State

Zip Code

User's Agency E-Mail:

 

 

 

 

 

Section 2 - OPWDD User ID & Access Request* DO NOT HANDWRITE IN SECTION 2

OPWDD USER ID Status: Select ONE option from drop down menu

Application Access Request:

Grant

Modify Role Revoke

Please use the below free version of

 

 

 

Adobe Acrobat Reader

 

 

 

to complete the form.

Select ONE application from drop down

 

 

 

 

 

Section 3 - Statement of Use To be read and signed by user requesting to USE OPWDD application(s).

Users are responsible for ALL activity performed with their assigned OPWDD User ID. Use is limited to conducting official business involving OPWDD. Any use, authorized or not, constitutes express consent for authorized personnel to monitor, intercept, record, read, copy, access or capture such information for use or disclosure in any manner without additional prior notice. Users have no legitimate expectation of privacy during any use of OPWDD systems. Unauthorized use or attempted unauthorized use is not permitted and may constitute a federal or state crime. Such use may subject you to appropriate disciplinary and/or criminal action. Clinical information, including records that identify or tend to identify individuals served or proposed to be served by OPWDD and its certified providers, is confidential and can only be disclosed in accordance with Mental Hygiene Law Sec. 33.13, HIPAA, and OCS. By signing below, you confirm that you have read, agree, understand the Section 3 "Statement of Use", confirm you have provided your legal (first, middle initial and last) name in section one (1) as well as confirm all information provided in sections 1 , 2 and 3 are correct.

User Signature(DO NOT COMPLETE THIS SECTION IF CLOSE OR REVOKE IS CHOSEN IN SECTION 2)

Date

Section 4 - Executive Approval To be read and signed by Executive Director or authorized designee listed with OPWDD.

Executive Director or authorized designee listed with OPWDD is required to sign, print and date when request of access or any modification /reactivation for section one (1) user. When employee is no longer employed with provider agency, it is the responsibility of the agency to submit a CLOSE request at that time (Sections 1, 2 and 4 ONLY). Failure to do so, may result in a potential HIPAA Violation. Requests for CLOSE OR Revoke of a specific application, is an exception and may be signed by the user, who is currently employed with the provider agency, supervisor OR manager in lieu of the Executive Director, with their name and title printed under their signature. By signing below, you confirm that you are listed with NYSOPWDD as an Executive Director/authorized designee for said agency notated in section 1, you have read, understand and, agree with the above statement and authorize the processing of the request for access made in Section two (2) by the user.

Signature, in section 4, without a printed name will NOT be accepted.

 

 

 

Executive Director Signature (or Authorized Designee signature)

 

Date

Executive Director printed Name (or Authorized Designee Name and Job Title)

Section 5 - Secure NYS OPWDD Application Authorizer Approval (if required) ONLY authorized OPWDD personnel should

sign in this section. This section is solely intended for users who have chosen an application in section 2 that has "*Note Section 5 Authorizer Required"; If you do NOT see this previously mentioned note in section 2, please do NOT alter this section in any way.

 

 

 

NYS OPWDD Application Authorizer Signature and Printed Name

 

Date

Form is REJECTED if sections 1 or 2 have ANY handwritten, false and/or missing pertinent information to process the request.

Submit completed form (that does NOT require section 5) or form related inquires to OPWDD IMS - External.Account.Provisioning@opwdd.ny.gov

Submit IR (IRMA) related requests or IRMA related inquiries to OPWDD IMU - Incident.management@opwdd.ny.gov

Submit QI (DQIA) related requests or inquiries to - quality@opwdd.ny.gov

Clear Form

Submit FA - Fire Portal requests or inquires to - Fire.portal.access@opwdd.ny.gov

Print Form

Instructions for Form IMS-01 (Revised 01/28/2019)

User ID and System Access Request Form Instructions

Form is REJECTED if sections 1 or 2 have ANY handwritten, false or missing pertinent information to process the request.

Staff who have NOT officially started working at the agency should NOT request access to the OPWDD systems.

Section 1 - User Information - Do NOT handwrite ANY information.

Please type ALL information requested, do NOT leave any box blank if requesting to use secure OPWDD application(s).

Provide LEGAL First name, middle initial and last name.

If no LEGAL middle name: type an “X”; user must submit their form and confirm they do not legally have a middle name OR middle name begins with an “X”, within the body of the e-mail submission.

Section 2 - OPWDD User ID & Access Request - Do NOT handwrite ANY information.

Part 1 - Select ONE option from the OPWDD User ID Status drop down menu.

OPWDD User ID - User has a User ID with Agency/agency ID provided in section 1. Go to part 2.

I do NOT have an OPWDD User ID* - User does not have an OPWDD User ID in system. Go to part 2.

Additional OPWDD User ID… - User currently has a User ID with a different agency/agency ID. Do NOT enter User ID. Go to part 2. Name Change - User needs to change last name ONLY. No other requests can be made at that time. Go to part 2.

Reactivate Access - 6 months or more since last login (user id account cannot be closed). Go directly to section 3.

Close OPWDD User ID - User no longer employed with agency/no longer need to use User ID account. Go directly to section 4.

*If user requesting more than one account/more than one application, only ONE form should have "I do not have an OPWDD User ID" selected.

Part 2 - Select ONE option from the Application Access Request (grant, modify role OR revoke).

Grant - User needs to gain access to a specific application. Go to part 3.

Modify Role - User needs to change their current role in CHOICES; the user MUST notate their User ID. Go to part 3. Revoke - User still with agency, needs to remove ONE application from User ID account. CLOSE cannot be chosen. Go to part 3.

Part 3 - Select ONE application from the second drop down menu

Select application needed. External Provisioning staff cannot provide the application needed nor a description of the applications.

Double check all information in section 1 and 2, correct issues, if necessary then print the form.

Section 3 - Statement of Use.

User should double check all information in section 1 and 2 if they did not complete those sections. User needs to read, sign and date.

If “Close OPWDD User ID” OR “Revoke” is chosen, Do NOT make any notation/marks/notes in section 3. Do nothing in section 3.

Section 4 - Executive Approval.

Obtain the Executive Director or AUTHORIZED designee listed with OPWDD signature, printed name and date section 4. Submit the completed form to the appropriate unit listed at the bottom of the form; do not submit this page.

Do NOT submit to the wrong unit or multiple units.

Section 5 - Secure NYS OPWDD Application Authorizer Approval

This section to be completed by a NYS employee ONLY and only if section 2 application chosen states Section 5 is required.

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