4986 Adams Rd.Rochester, MI 48306
Medical Support(248) 475-4701(248) 475-5777 FAX
Please indicate the Managed Care Liason, Office Manager or Primary Physician for your practice.
Please note, upon your completion of this request, the person indicated below will be contacted for verification.
This document is accepted as a contract and the signatory accepts responsibility for appropriate use, dissemination, and
confidentiality of all information made available by Medical Network I, P.C. This includes oral, paper-based, electronic communication
and transfer of data to any electronic form, storage or database. It is understood that a personal logon id and password
constitutes an electronic signature. Use of the personal logon id to access patient information is equivalent to using a signature.
The signatory is accountable for all access using one's personal logon id. Any unauthorized access using one's personal
logon id. is not allowed. This is regarded as a HIPAA violation, a breach of confidentiality and medical ethics. The signatory
acknowledges that the system records all activities performed using one's personal unique logon id, and that access attributed
to the personal logon id will be recognized as having been performed by you. Access to PODS and all information provided is
subject to professional confidentiality obligations, state and federal laws, including but not limited to HIPAA privacy and
security standards. The signatory accepts responsibility for compliance with HIPAA regulations, state laws and processional
obligations, and understands that non-compliance may result in civil and/or criminal legal actions, state and/or federal penalties
and fines. The signatory acknowledges that a unique Medical Network I, P.C. logon id and password has been and will be kept
confidential. The signatory acknowledges that any indications of misuse will suspend or terminate access to PODS and could
result in civil and/or criminal legal actions, state and/or federal penalties and fines.