Form F-00639 "Agency Data Security Staff User Agreement" - Wisconsin

What Is Form F-00639?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-00639 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-00639 "Agency Data Security Staff User Agreement" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
Wis. Stat. § 15.04(1)(m), Privacy Law
F-00639 (02/2020)
AGENCY DATA SECURITY STAFF USER AGREEMENT
Personal information you provide may be used for secondary purposes.
INSTRUCTIONS: After completing the signatures, email this form to dhscaresaims@dhs.wisconsin.gov.
Name – Agency
Name – Security Officer (Last, First MI)
Title
Employing Agency
Work Address
Phone Number
Fax
Email Address
Name – Backup Security Officer (Last, First MI)
Title
Employing Agency
Work Address
Phone Number
Fax
Email Address
Name – Backup Security Officer (Last, First MI)
Title
Employing Agency
Work Address
Phone Number
Fax
Email Address
I have read the client confidentiality regulations covered by state policy and federal/state statutes and understand their
relationships to authorizing access to client information. I will ensure such confidentiality in accordance with Wis. Stat.
§§ 49.81 and 49.83.
User Agreement for Access to the Wisconsin Department of Health Services (DHS) Systems
I have a legal and ethical responsibility to protect the confidentially and security of all protected data and information to
which I have access via the DHS system application(s). Confidential information may include, but is not limited to:
financial information, client/patient identifiable information, or protected health information. This information is protected by
state and federal laws. In order to be granted data about DHS clients that we serve, I agree to the following:
I will not in any way access, use, divulge, copy, release, sell, loan, review, alter, or destroy any confidential information
except as properly and clearly authorized within the scope of my job and all applicable policies and laws. I will not re-
disclose any information I have accessed unless needed to complete my authorized task and as allowed by law.
I acknowledge the receipt of my IDs and passwords. I understand that passwords are the equivalent of my signature and
that I am responsible for their use.
If I know of an actual or attempted privacy or security violation or inappropriate use or disclosure of this data, I will notify
my security officer and supervisor.
It is my responsibility to inform my supervisor and security officer in writing when I am leaving employment. When my
association ends, I will no longer access confidential information and will not take any confidential information with me.
I understand that my actions in this system may be intercepted, monitored, recorded, copied, audited, inspected, and
disclosed to authorized personnel. Any improper use or unauthorized access of this system may result in administrative
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
Wis. Stat. § 15.04(1)(m), Privacy Law
F-00639 (02/2020)
AGENCY DATA SECURITY STAFF USER AGREEMENT
Personal information you provide may be used for secondary purposes.
INSTRUCTIONS: After completing the signatures, email this form to dhscaresaims@dhs.wisconsin.gov.
Name – Agency
Name – Security Officer (Last, First MI)
Title
Employing Agency
Work Address
Phone Number
Fax
Email Address
Name – Backup Security Officer (Last, First MI)
Title
Employing Agency
Work Address
Phone Number
Fax
Email Address
Name – Backup Security Officer (Last, First MI)
Title
Employing Agency
Work Address
Phone Number
Fax
Email Address
I have read the client confidentiality regulations covered by state policy and federal/state statutes and understand their
relationships to authorizing access to client information. I will ensure such confidentiality in accordance with Wis. Stat.
§§ 49.81 and 49.83.
User Agreement for Access to the Wisconsin Department of Health Services (DHS) Systems
I have a legal and ethical responsibility to protect the confidentially and security of all protected data and information to
which I have access via the DHS system application(s). Confidential information may include, but is not limited to:
financial information, client/patient identifiable information, or protected health information. This information is protected by
state and federal laws. In order to be granted data about DHS clients that we serve, I agree to the following:
I will not in any way access, use, divulge, copy, release, sell, loan, review, alter, or destroy any confidential information
except as properly and clearly authorized within the scope of my job and all applicable policies and laws. I will not re-
disclose any information I have accessed unless needed to complete my authorized task and as allowed by law.
I acknowledge the receipt of my IDs and passwords. I understand that passwords are the equivalent of my signature and
that I am responsible for their use.
If I know of an actual or attempted privacy or security violation or inappropriate use or disclosure of this data, I will notify
my security officer and supervisor.
It is my responsibility to inform my supervisor and security officer in writing when I am leaving employment. When my
association ends, I will no longer access confidential information and will not take any confidential information with me.
I understand that my actions in this system may be intercepted, monitored, recorded, copied, audited, inspected, and
disclosed to authorized personnel. Any improper use or unauthorized access of this system may result in administrative
AGENCY DATA SECURITY STAFF USER AGREEMENT
Page 2 of 2
F-00639
disciplinary action and civil and criminal penalties. By signing this form and continuing to use DHS system(s), I consent to
these terms and conditions.
By signing this form, I indicate that I am the person named and that I adopt this entry as my legal electronic signature on
this document.
SIGNATURE – Security Officer
Date Signed
Name
Title
SIGNATURE – Backup Security Officer
Date Signed
Phone Number
Email Address
SIGNATURE – Backup Security Officer
Date Signed
SIGNATURE – Agency Director
Date Signed
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