Get Provider End User Security Agreement Form - State Of Oklahoma ... - Ok

This guide will assist you in completing the Provider End User Security Agreement Form required by the State Of Oklahoma. Following these steps will ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the Facility/Company Name in the designated field. It is essential to attach a list of all related entities for which this account will be authorized, along with the applicable facility/provider license number for each entity.
3. In the License Number field, provide the facility/provider license number for each facility that can be accessed under this account. If there is only one facility, enter the license number directly. If applying through a staffing agency or as an independent contractor, indicate this as applicable.
4. Complete the personal information section by filling in your First Name, Middle Initial (if any), and Last Name.
5. Fill in your Address details accurately. Make sure it matches your official records.
6. Create a Proposed User Name that you would like to use for accessing the OK-SCREEN. Additionally, provide your phone number and Email address for communication purposes.
7. Read the Provider End User Security Agreement terms carefully. This section emphasizes the importance of securing your username and password and the responsibilities associated with them.
8. Sign the form to acknowledge that you have read, understood, and accepted the terms outlined in the agreement. Also, include the date of signing.
9. An authorized officer of the licensed operating entity must also sign the form. This individual should print their name, provide their official title or position, and indicate the date of their signature.
10. Once the form is completed, fax or email it to the designated contact at the Oklahoma State Department of Health as provided.

Complete your Provider End User Security Agreement Form online to ensure compliance and access to necessary services.