ࡱ> FHCDE%` bjbjNN ,,'j 2Z@Z@Z@8@<A2eC$GGGG!JJ\K0ddddddd$gh=je1OI@!J1O1OeGGeQQQ1O^8GGdQ1OdQQ[\GC Z@O^p\4_e0e\^jO`j,\j\PEKULQMM~EKEKEKeeMQ^EKEKEKe1O1O1O1O2226%$2226%222   SHAPE \* MERGEFORMAT  Department of Public Health Womens & Childrens Health Section 1914 Mail Service Center, Raleigh, North Carolina 27699-1914 Tel 919-707-5800 ( Fax 919-870-4863USER ID SERVICE REQUEST for WIC ACCESS in HSIS Employee InformationFill out this section completely for all requests. Please print or type.01. Employee Name:  FORMTEXT      02. Position:  FORMTEXT      03. Program Code:  FORMTEXT      04. Site No:  FORMTEXT      05. Bill Code:  FORMTEXT      -NER06. County Code:  FORMTEXT      07. Agency Name:  FORMTEXT      08. County Name:  FORMTEXT      09. Street Address:  FORMTEXT      10. City:  FORMTEXT       , NC11. Zip:  FORMTEXT      12. Email Address:  FORMTEXT      13. Main WIC Phone Number: (  FORMTEXT     )  FORMTEXT      14. WIC Fax number: (  FORMTEXT     )  FORMTEXT       Request New User ID 15.  FORMCHECKBOX  Full WIC Access 16.  FORMCHECKBOX  View Only WIC Access 17.  FORMCHECKBOX  XPTR/XNET Access 18.  FORMCHECKBOX  Other (Explain):  FORMTEXT       Please complete the following information, if known, for New User ID and Transfer User ID Requests: 19. Remote Terminal ID:  FORMTEXT       20. Voucher Station Number:  FORMTEXT       21. Report Printer Node:  FORMTEXT       22. MICR Printer Node:  FORMTEXT        Change Existing User ID 23. **Enter Current User ID:  FORMTEXT       ** (Required for All User ID Change Requests) 24. WIC Access Level Change 24a.  FORMCHECKBOX  Request Full Access 24b.  FORMCHECKBOX  Request View Only Access 24c.  FORMCHECKBOX  Remove WIC access from Non-WIC User ID 24d. Request  FORMCHECKBOX  Read  FORMCHECKBOX  Write  FORMCHECKBOX  Delete Access to Specific Screen #  FORMTEXT       24e.  FORMCHECKBOX  Remove Access from Screen #  FORMTEXT       25.  FORMCHECKBOX  Terminate WIC User ID Effective Date:  FORMTEXT       26. Other 26a.  FORMCHECKBOX  (Explain)  FORMTEXT       26b.  FORMCHECKBOX  Change/Correct User Name:  FORMTEXT       26c.  FORMCHECKBOX  Add XPTR/XNET Access 26d.  FORMCHECKBOX  Remove XPTR/XNET Access 27. Transfer User ID (Fill out all below as well as #18 - #21) 27a. Old End date:  FORMTEXT       27b. Old Agency Name:  FORMTEXT       27c. New Start date:  FORMTEXT       27d. New Agency Name:  FORMTEXT       (For NSB Helpdesk Use Only) RACF ID # Date Completed: Initials:  FORMCHECKBOX  NCTE  FORMCHECKBOX  PW  FORMCHECKBOX  HSIS  FORMCHECKBOX  XLS  FORMCHECKBOX  XPTR/XNET Access  FORMCHECKBOX  IRM  FORMCHECKBOX  Created Notification Letter  FORMCHECKBOX  Faxed/Emailed WIC Director  FORMCHECKBOX  Remedy Ticket _________________  AuthorizationI am the WIC director for this program/site and I authorize the requested User ID service.28. Signature of WIC Director29. Print Name of WIC Director30. Date Signed:  FORMTEXT      31. Phone Number: (  FORMTEXT     )  FORMTEXT      Do not sign this form before it has been filled out. Please fill out a Confidentiality Agreement form for New User ID, Transfer User ID or Name Change requests only. 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Division of Public Health Women s & Children s Health Section 1914 Mail Service Center Raleigh, North Carolina 27699-1914 Tel 919-707-5800 ( Fax 919-870-4863 USER ID SERVICE REQUEST for WIC ACCESS in HSIS HSIS CONFIDENTIALITY AGREEMENT FOR NEW USER ID, TRANSFER USER ID, AND NAME CHANGE REQUESTS The State Center for Health Statistics (SCHS) recognizes the need to maintain the confidentiality of information received from any individual. In case of medical records, the right to confidentiality is guaranteed under North Carolina law (General Statutes 130A-143, 130A-93, 130A-12, and 130S-374) and these data can only be released with approval of the Director of SCHS. Additionally, in accordance with G.S. 130A-93 (e), medical information obtained from birth certificates can only be released upon approval of the State Registrar. As part of the State Center for Health Statistics, the Health Services Information System (HSIS) is a collection point for data from many public health agencies. Because this data contains personal identifiers that must remain secure and confidential: I agree to access information in HSIS only on a  need to know basis. I will not divulge, copy, or release any information from HSIS to any unauthorized person or persons. I understand that prior written permission for release of any data collected in HSIS must be obtained from the source of that data. I will not release my User ID or password to anyone else, nor do I approve of anyone else accessing or altering information in HSIS using my ID. I understand that I am responsible for the quality of the data I enter into HSIS. Failure to comply with these policies will result in User privileges being revoked. That failure may be subject to disciplinary action under laws of the State of North Carolina.  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