New Customers | COMPdata Informatics

Facility Type:	Hosptial ASTC
Users Facility Name:
Facility Address:
City:
State:
ZIP code:
New User First Name:
New User Last Name:
Title:
Phone Number:
New User E-mail :	Enter your business e-mail address to establish a login ID.
Choose a User Type:	Primary- One per account/Main account manager Secondary - Backup to Primary account manager General Access - Data submission functions
	I have read and agree User Account and HIPAA Compliance: Users must maintain a current password to continue system access and/or system generated reports and other notifications. Passwords expire every 90 days. E-mail notifications are sent 10 days prior to an accounts deactivation. A Primary User is designated for each facility in order to manage User accounts. Primary users must contact us immediately of a User’s status change e.g. separation of employment, or duties and ensure inactive accounts are removed from our system. The COMPdata Data Submission System contains PHI. Sharing of IDs and password of your personal account are strictly prohibited. Submission of PHI to COMPdata via e-mail must be done through a secure email system with encryption. Failure to do so will result in legal action taken against you to the full extent of the HIPAA compliance act and IHA's legal department.
Replacing User:	Yes No Prior User unkown If yes, please provide the prior Users information below.
Replacing First Name:
Replacing Last Name:
Effective Date:	Today
Upload Proof of Authorization:	Instructions: Upload written authorization from the facility CEO or authorized Designate. Secondary, authorization from the COMPdata Primary Coordinator.

User Application-Data Submission/Coordinator