North Florida hCare Access Help

Security Access Form Completion Instructions

Getting Stuck? Email us at

Office Manager or Equivalent

  1. Complete all required fields on the Security Access Form by Clicking Here.
    • If you need additional CSA forms you can Click Here to fill out and print.
  2. NOTE: If you are using the Chrome browser please open the file from your downloads folder to view it.
  3. Print Form
  4. Sign and date SAF

Office Staff

  1. Read Confidentiality and Security Agreement (CSA)
  2. Sign and date SAF and CSA


  1. CSA and SAF given to requesting physician for review
  2. Sign and date SAF

SAF and CSA forms are either:

Study Hall - Lets Review!

The CSA reminds each of us of our legal and ethical responsibility to safeguard our patients' privacy, as well as other types of sensitive information (dependent upon your role and responsibilities).
Bottom line: you are accountable for protecting the information entrusted to you. When you signed the CSA, you affirmed that you will:


  • Access and use confidential information only as necessary to perform job-related duties.
  • Take reasonable safeguards to protect conversations from unauthorized listeners.
  • Keep passwords, PINs, and access codes private.
  • Practice good workstation security measures, such as positioning screens away from public view.
  • Use only approved licensed software.
  • Use a device with virus protection software.
  • Notify the Physician Support Coordinator of user inactivation's.


  • Disclose or discuss any confidential information with anyone who does not need to know it.
  • Publish or disclose any confidential information to others using personal email or any Internet blogs or sites, including social media.
  • Copy, store, or take home confidential information on paper, mobile devices, portable devices, or removable media unless your manager approves.
  • Use tools or techniques to break/exploit security measures.

Please read the following detailed requirements and instructions on how to successfully complete our request of access forms electronically. Failure to fill out the form correctly will result in a delay of account creation. All four (4) pages of the form are required to process your application. Once complete, fax to the number provided at the bottom of the form.

If an option in the drop down field is not available. You may type in the option that is needed.

Fields marked with an asterisk (*) and highlighted in Red must be fully completed in order to gain access to HCA’s Patient Information Systems.

Why is my Social Security Number and Date of Birth required?

  • By law (the HIPAA Security Rule) HCA must have a mechanism to uniquely identify users with access to electronic Protected Health Information (ePHI), and verify their access and activities are necessary and appropriate through periodic reviews, activity monitoring, and audits.
  • HCA must have a mechanism to uniquely identify each user on our network for government, law enforcement, and civil/legal discovery requests for logs and evidence of activities.
  • HCA also must have a unique identifier to correlate network user access with other key business processes such as background checks, the OIG List of Excluded Individuals/Entities, reports on disclosure of PHI, screening for terminated workforce members, and credentialing.
  • Please contact us at if you would like to receive full documentation on this requirement.
  • If you have any questions please feel free to contact us at
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