EIS Access/Removal Request and Staff Update Form

If you are a provider of mental health services for adults affiliated with the Office of Substance Abuse and Mental Services, you should complete this form for:

• Complete this form to request :
  • Staff access to EIS
  • Removal  of access to EIS due to staff resignation or change in data entry responsibilities
  • Password reset
  • Changes in staff names, agency of employment, office location, phone number, or email.

I want to... (select one)	Select One Request EIS Access Remove EIS Access Reset My Password Change Staff Persons Office Location Change Staff Persons Name
First Name:
Last Name:
Previous Name: (If last name changed within the past 3 months)
Agency:
Agency Address: (Your designation location)
Previous Agency/Location: (If changing locations)
Staff's Contact Phone:
Staff's Email Address:
Effective Date (mm/dd/yyyy):
Supervisor's Name:
Supervisor's Phone:
Supervisor's Email:
Supervisor's Location:
Comments:
Confidentiality Statement:	By checking this box, you agree that to the extent that the Provider seeks to use, access, maintain, or disclose information in the EIS system that actually or reasonably could identify an individual or consumer receiving benefits or services from or through the Department ("Protected Information"), the Provider agrees to a) maintain the confidentiality and security of such Protected Information as required by applicable state and federal laws, rules, regulations and Department policy, b) contact the Department within 24 hours of a privacy or security incident that actually or potentially could be a breach of Protected Information and c) cooperate with the Department in its investigation and any required reporting and notification of individuals regarding such incident involving Protected Information. To the extent that a breach of Protected Information is caused by the Provider or one of its subcontractors or agents, the Provider agrees to pay the cost of notification, as well as any financial costs and/or penalties incurred by the Department as a result of such breach.