Assessment and Account Request
Reference Number: 

You are completing a form requesting access to the Shared Care Portal ("Portal") of Visiting Physician Association ("VPA").
Organization Name:
Facility Name:
Facility Address:
Facility City:
Facility State:
Facility Zip Code:
First Name:
Last Name:
Job Title:
Business Email:

We use your Business Email address to communicate the status of your registration, and other events of importance. Your email address will not be given to patients.

Phone Number:

We will contact you regarding your account using the phone number you enter.

First Name:
Last Name:
Job Title:
Credentials:

Example: LPN, RN, NP, MD, SW, etc.

User ID:

Please create a user id and password that the Administrator will use to log in to the Administrator account. The user id can have only letter, numbers, dashes or underscores - no spaces.

Password:

The password must be at least 12 characters long, and contain a mix of uppercase, lowercase, numbers, and special characters (at least 1 character from each of those 4 groups).

Confirm Password:

To assure accuracy, please confirm your password by entering it again. The password and the confirmation must match.

Choose a Security Question:
Answer:
Name Title Credentials
Does your organization electronically send any claims or health care transactions for these services?

For example, if you bill Medicare/Medicaid directly using an electronic system, answer "yes". If all of your patients are private pay, and you don't send any electronic claims or transactions to Medicare/Medicaid or any insurance company for payment, answer "no".

Yes

No
Does your organization have a compliance program in place that includes the privacy and security of patient/resident information?

Yes

No

Please list the name(s) and phone number(s) of the Privacy/Security/Compliance Officer(s) at your organization.
Name Phone Email

Is your staff trained on how to properly protect the privacy and security of patient/resident information when they first work for your organization and at least annually thereafter?

Yes

No

If Yes, attach copies of your privacy and security policies and procedures.



Does your organization routinely audit or monitor the privacy or security of your patient/resident information?

Yes

No

If yes, briefly describe these audits and/or monitors and their results.



Does your organization routinely perform background checks or similar reviews of both your new and current staff? Background checks include exclusion checks required for most health care providers under federal law.

Yes

No


If yes, please explain your process including how often you perform these checks.

Has your organization received a complaint about, been investigated for or been named in a lawsuit involving the misuse, or breach/lack of privacy or security of resident information (including identity theft) within the past 12 months?

Yes

No


If yes, please describe.

Has your organization disciplined a staff member involving the misuse, or breach/lack of privacy or security of resident information (including identify theft) within the past 12 months?

Yes

No


If yes, please describe.

The person signing below must be the person making this request, listed above under Requestor Information.

I represent and warrant the information contained in this Form is accurate and complete to the best of my knowledge based on reasonable due diligence and that I am an authorized representative of my organization.

I represent and warrant that the organizations in this request are health care providers who will use the patient information found on our Portal only for health care services. Patient information usually includes lab tests, medications and provider visit notes. If my organization needs access to less than this, I will indicate my preference below.

Please provide all available patient information (lab tests, medications and provider visit notes)

Please provide only limited patient information

By typing my first and last name below, I understand and agree that this form of electronic signature has the same legal force and effect as my handwritten signature.


Signature:

Please enter your 6 digit reference number now:


No reference number? First time here?

• You need a reference number to save your form and return to your work later.

• You will probably find it convenient to work on your form over a period of more than one session, since that is easier than doing all of your entries in one session.

• After you receive your reference number, please write it down for future reference.

Yes, please give me a reference number.