Otsuka Digital Health (“ODH”) solution
ACCESS REQUEST FORM
This form must be typed or completed on a computer and printed out for signatures in order to be processed.
Submit this form and other required documents by email to ODHAccess@SFBHN.org.
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INFORMATION FOR REQUESTER OF ACCESS (“Requester”)
1.
First Name:
Last Name:
2.
Provider ID:
Provider Name:
3.
Circuit:
4.
Fax:
5.
Mailing Address:
6.
Job Title:
County:
Phone:
Ext.:
E-mail:
Staff ID:
AUTHORIZATION SIGNATURES:
1.
Supervisor’s Name:
Job Title:
2.
Supervisor’s Signature:
Date:
3.
Managing Entity Officer’s Name:
4.
Managing Entity Officer’s Signature:
Date:
ODH ROLE FOR REQUESTER (Choose only one. Please refer to role descriptions on the following page if needed):
Intake Specialist
Discharge Specialist
Care Coordinator
Referral Coordinator
Clinician
Clinical Supervisor
Clinical Administrator
Provider Supervisor
SFBHN SOC
SFBHN System Administrator
If the Requester has selected the Clinician or Clinician Supervisor role, they must provide their License Number:
4.
ACTION REQUESTED (Choose only one):
Add New User
Deactivate User
Reactivate User
Update User Information
Date action should be initiated: ____________________
If the Requester has an existing ODH Login ID, please provide it:
5.
6.
SERV-U ACCESS (Choose only one. Please refer to Serv-U descriptions on the following page if needed):
None
Communications + Reports
Data Upload / IT
Deactivate
If the Requester has an existing Serv-U Login ID, please provide it:
SFBHN System Administrator
CONFIDENTIALITY AND SECURITY REQUIREMENTS
By my signature, I acknowledge that I will only access or view information or data for which I am authorized and have a legitimate business
reason in the course of the performance of my duties. I shall maintain the integrity, security and confidentiality of all sensitive information
accessed, and will not use any of the information for any independent or unauthorized purposes.
I acknowledge that this information is governed by confidentiality and security provisions of several state and federal laws including:
1.
42 Code of Federal Regulation Parts 2 and 142 – Confidentiality of Alcohol & Drug Abuse Patient Records
2.
45 Code of Federal Regulation Parts 160 and 164 – Health Insurance Portability & Accountability Act
3.
Section 394.4615, Florida Statutes – Clinical Records; Confidentiality
4.
Section 397.501(7), Florida Statutes – Rights of Individuals Receiving Substance Abuse Services
5.
Section 916.107(8), Florida Statutes – Confidentiality of Clinical Records for Mentally Deficient and Mentally Ill Defendants
6.
Section 282.318, Florida Statutes – Enterprise Security of Data and Information Technology Act
In addition, the Security Agreement Form imposed confidentiality and security obligations for any data to which I may have access in my
normal course of duties.
I have taken training on HIPAA, and other applicable federal and state laws on (date): _____________. I understand that I am required to retake
HIPAA and other applicable training at least on an annual basis or upon any significant change in the laws.
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I understand that any violation of these CONFIDENTIALITY AND SECURITY REQUIREMENTS may result in the deactivation of my
Otsuka Digital Health solution user account and may subject me to disciplinary action. I also understand that I have an obligation to report any
misuse of or an incident pertaining to the access to the system. Current user log on credentials:
Requester Name:
Requester Signature:
Date:
ROLE DESCRIPTIONS:

Intake Specialist:
At most agencies, the Intake Specialist role has the first interaction with the consumer. An Intake Specialist will use ODH to create a
consumer profile, which includes:
- Identity and demographic information
- Financial eligibility information
- Obtain and document appropriate consent

Discharge Specialist:
The Discharge Specialist role at an Agency uses ODH to track and document a consumer's discharge from the care of the Agency after
completion of services. They coordinate with the Care Coordinator and Clinician to ensure the required documentation is completed as part
of the process. They have the final interaction with the consumer.

Care Coordinator:
The Care Coordinator organizes resources and services for a consumer across their complete health care cycle at a particular Agency, from
intake through discharge.
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Referral Coordinator:
The Referral Coordinator uses ODH to set up Referral Requests to other providers within the SFBHN Network and tracks the referral
acceptance or rejection.
At the receiving provider, this role uses ODH to accept or reject referral requests from other providers or SFBHN, when the referral
requires prior authorization.
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Clinician:
The Clinician at an Agency is a certified behavioral healthcare professional, responsible for diagnosis, care, and treatment of consumers.
They will use ODH to manage clinical data of the consumers, including the creation of Care Plans, Treatment Plans, and Assessments, as
necessary.
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Clinical Supervisor:
The Clinician Supervisor supervises the work of the Agency's clinician’s or other health care professionals, who are directly responsible for
consumer diagnosis, care planning and treatment. They use ODH as a tool to:
- Assign consumers to Clinician role workloads and to prioritize work
- Approve Care Plans and other work as designated by the Agency
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Clinical Administrator:
The Clinical Administrator supports Clinicians by completing administrative tasks, such as data entry, providing necessary documentation,
and retrieving any consumer’s health information.
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Provider Supervisor:
The Provider Supervisor manages the agency’s business operations, including consumer healthcare. They will use ODH to view data only,
including all personal health information across the consumer’s health care cycle at the agency.

SFBHN SOC:
The SFBHN System of Care, or SOC, role uses ODH to manage three functions of SFBHN, which are:
- Utilization Management
- Resource and Waitlist Management
- Provider and Service Administration
This role complies with Utilization Management rules in managing authorizations for services through ODH for review, approval, or
denial. This role also monitors and manages the Resource Waitlists, keeping them current. Also enrolls Providers and Services into ODH
and set limits for service.

SFBHN System Administrator:
The SFBHN Administrator role is responsible for the configuration management of the ODH system at SFBHN. This role manages the
following activities:
- Duplicate consumer data
- Monitors data integrity
- Configures provider agencies and users
- Grants access permissions
- Service data setup and editing
SERV-U DESCRIPTIONS:
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
Communications + Reports:
This user has access to read provider specific reports created by SFBHN and access to read or upload files in the communications folder.

Data Upload / IT:
The Data Upload / IT user is responsible for uploading Agency files on behalf of Batch Upload Providers to the ODH Web Portal. This
user also has access to the Communications and Reports folders.
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SFBHN System Administrator:
The SFBHN System Administrator is responsible for the configuration management of the Serv-U system at SFBHN.
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