USER ACCOUNT AGREEMENT
for
Mecklenburg County Health Department
CAREWare System
If you would like to apply for a CAREWare User Account, please fill out the following information. You will
be contacted with confirmation of your account (including user id and password).
Please print clearly
Section 1: CAREWare User Account Information (all information is required)
1. PROVIDER NAME:
2. PROVIDER LOCATION:
3. NAME (FIRST, MIDDLE INITIAL, LAST):
4: POSITION (TITLE):
5. BUSINESS PHONE:
7. SUPERVISOR NAME:
6. BUSINESS FAX:
8. SUPERVISOR PHONE:
10. E-MAIL ADDRESS:
11. AUTHENTIFICATION WORDS: Remember these words. You may be asked to identify yourself with this
information if you call to reset your password.
a. Your mother’s maiden name:
b. Your city of birth:
I understand that as a CAREWare system account holder, I agree:
•
That my User ID and password is for my exclusive use and may not be loaned to or used by anyone else. If I
leave the employment of the PROVIDER, no longer require access because of a job change, or
authorization to access CAREWare is revoked by the PROVIDER, it is the joint responsibility of me and my
employer to immediately notify Mecklenburg County Health Department (MCHD).
•
That I have read, understand, and will comply with all HIPAA regulations and all other applicable state
and federal administrative rules, laws and regulations
•
To ensure the computer I use to run the CAREWare system receives regular operating system patches and
virus scans with up-to-date virus definitions.
•
To immediately report to MCHD all incidents of improper access, information misuse, or unauthorized
dissemination of information.
•
To the password requirements MCHD has in place for access to the CAREWare system (minimum of 8
characters in length and required to be changed every 30 days).
•
That the data contained within and used by the CAREWare system contains confidential and sensitive
information.
12. USER SIGNATURE:
13. DATE:
Section 2: Provider Approval (all information is required) Section to be completed by Provider
Authorized Representative.
14. Authorized Representative Printed Name:
15. Authorized Representative Signature:
16. Date:
17. Phone Number:
The completed form shall be sent to MCHD for each user needing CAREWare access. Please fax to (704) 227-0298.
Section 3: For MCHD Use Only
Date Received:
Date Authenticated:
User Name:
Note:
Mecklenburg County Health Department
By:
Rev. 3/18/2008