Client Portal Authorization Form

Access & Protected Health Information (PHI)

The BWBA Client Portal may provide access to Protected Health Information (PHI), which includes any identifiable information related to an individual’s health, care, or payment for care.

Access to PHI should be limited to individuals who require it to perform their job responsibilities. Please carefully consider which users within your organization should have access. All authorized users are expected to comply with applicable privacy and security requirements.

Authorized users of your Agency or Brokerage may also be added using this form.

Please complete the form below.

Authorized HIPAA Privacy Officer(Required)
Please list all Users below.(Required)
First Name
Last Name
Email Address
Company Name
Will user have access to view member PHI?
Will the User have access to Reporting when available?
Do you wish to remove this user?
Group ID Number
 

Client Authorization & Certification

By completing and submitting this form, the undersigned certifies that:
  • All individuals listed for access to the BWBA Client Portal have been trained on HIPAA privacy and security policies and procedures
  • Each authorized user understands their responsibility to protect the confidentiality and security of Protected Health Information (PHI)
  • Access has been granted based on a legitimate business need related to plan administration
  • The organization authorizes BWBA to provide portal access to the individuals listed on this form
The undersigned further agrees to notify BWBA promptly of any changes to authorized users, including role changes, terminations, or removal of access privileges.