Please fill in the form below to register for the HCHB Provider Link Portal. For assistance, call support at 1-917-675-2252. "*" indicates required fields Email* Enter Email Confirm Email Name* First Last Clinical / Practice Name*Address* Street Address Address Line 2 City State ZIP / Postal Code Phone*Are You a Physician?* I Am a Physician I Am Not a Physician My Role*Select RoleNurse PractitionerRegistered NursePhysician AssistantResidentOffice StaffMy NPI Number*License Number*MD Medicaid Registered* Yes No Unsure MD PECOS* Yes No Unsure Taxpayer Identification Number (TIN)HospitalDepartment Physician Information As a non-physician, your account must be associated with at least one physician in your office. This association will allow you to log on and view clinical information for patients of authorizing physicians. Associated PhysicianAssociated Physician 2Associated Physician 3Associated Physician 4Associated Physician 5Associated Physician 6 AGREEMENT This Physician Portal Access Agreement is for the purpose of allowing the staff member to review the electronic records of the authorized practitioner’s patients who are receiving the services of VNS Health and its affiliates, and to facilitate physician-agency communication regarding patient service. The Portal System user will use and disclose protected health information in accordance with the requirements for covered entities under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all applicable State laws. The Portal System user will hold all information in strictest confidence in the processing and storage of all data. Each authorized portal user will be assigned an individual password or access code by VNS Health. The Portal system user hereby agrees that no one else will be allowed to use his or her password or access code. Signed staff security statements and access code identification files will be secured and maintained in the physician’s office. Information via remote terminals will be filtered through these passwords and security checks creating an audit trail to identify individual users when necessary. Only an authorized practitioner may authenticate home health care patients’ orders per CMS regulation. Under no circumstances will the physician’s office staff member authenticate or authorize medical orders on behalf of the physician using the physician’s password. As a user of this portal system, and signatory to this agreement, I hereby agree to these terms of usage. Confirmation of Agreement* I agree Physician NPI NumberLicense NumberMD Medicaid Registered* Yes No Unsure MD PECOS* Yes No Unsure Taxpayer Identification Number (TIN)HospitalDepartmentService ADDITIONAL PRACTICE LOCATION Clinical / Practice NameAddress Street Address Address Line 2 City State ZIP / Postal Code Phone ADDITIONAL PRACTICE LOCATION Clinical / Practice NameAddress Street Address Address Line 2 City State ZIP / Postal Code Phone ADDITIONAL PRACTICE LOCATION Clinical / Practice NameAddress Street Address Address Line 2 City State ZIP / Postal Code Phone AGREEMENT In consideration for utilizing VNS Health I certify that I am a Physician licensed to practice medicine in the State of New York, and I agree as follows: This Physician Portal Agreement is for the purpose of allowing physicians to review the electronic records of their patients who are receiving the services of VNS Health and its affiliates, to authenticate their medical orders via the portal, and to facilitate physician-agency communication regarding patient service. The Portal System user will use and disclose protected health information in accordance with the requirements for covered entities under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Portal System user will hold all information in strictest confidence in the processing and storage of all data. Only authorized personnel will have access to electronic data accessible via the portal or to any data printed from the portal. Patient information will be accessible only as appropriate to a particular physician’s portal and its authorized users. Each authorized portal user will be assigned an individual password or access code by VNS Health and will complete a signed statement that no one else will be allowed to use his or her computer key. Signed staff security statements and pass code identification files will be secured and maintained in the physician’s office. Information via remote terminals will be filtered through these passwords and security checks creating an audit trail to identify individual users when necessary. Only an authorized practitioner may authenticate home health care patients’ orders per CMS regulation. Under no circumstances will the physician’s office staff member authenticate or authorize medical orders on behalf of the physician using the physician’s password. As a user of this portal system, and signatory to this agreement, I hereby agree to these terms of usage.Confirmation of Agreement* I agree Δ
