Site Portal Administrator Registration form

By completing this form you are requesting to be the Administrator for the Provider Portal with the TaxID number and Clinic/Business entered or noted below.

User Information

• First Name *
• MI
• Last Name *

• Email *
• Confirm Email *

• Username *
• Job Title *

• Password *
  weak
• Confirm Password *

Security Question

• Security Question *

• Security Answer *

Clinic/Business Information

• Clinic/Business Name *

• Address *

• City *
• State *
• Zip Code *

• Phone *
• Ext
• Fax *

• Provider Tax ID *

• Office Admin First Name *
• MI
• Office Admin Last Name *

Provider Information

• Provider First Name *
• MI
• Provider Last Name *

Other Information

• Providers associated with this business

• Medical Groups associated with this business

• Additional Notes

• Enter the code shown:
  
  

• HIPAA Regulations and User Access Agreement

   USER ACCESS AGREEMENT

  In order to access and use the internet-accessible health care information system furnished by Altura Management Services LLC (“AlturaMSO”), including but limited to, AlturaMSO’s Connect system (as further described in Section 1 below, the (“System”) you must agree to comply with the terms of this agreement. If you do not agree to comply with the terms of this agreement, then you are not authorized to use the System, and you must not access or otherwise use the System, or permit any other persons to do so. Accordingly, in consideration of the covenants, conditions, representations, warranties and restrictions set forth herein, you agree as follows:

   

  1. System. For purposes of this agreement, the System means and refers to all of AlturaMSO’s health care information databases, software and systems that are accessed and used by you and other users. Except for the permission granted hereunder, all rights and interests in and to the System are expressly reserved by AlturaMSO, and you agree not to take, or to authorize or permit others to take, any action that will interfere with or diminish any rights, title or interests of AlturaMSO in the System.

   

  2. Grant of Permission. AlturaMSO hereby grants to you the revocable, non-exclusive right to use the System, subject to and in accordance with this agreement, and such communications media, access controls, policies and procedures and security mechanisms as may be established by AlturaMSO from time to time during the term of this agreement for access to and use of the System, without any right to sub-license or otherwise assign or transfer any of the rights granted hereunder, and at all times subject to the covenants, conditions, warranties and restrictions set forth in this agreement.

   

  3. Group Administrators. To the extent applicable, any designated Group Administrators (primary or secondary) shall, in additional to all covenants, conditions, representations, warranties and restrictions set forth herein, be responsible for creating users, activating and deactivating user and their access to the System and granting user’s access to User Data (as such term is defined below).

   

  4. Use Limitations. You agree not to use, or to authorize or permit others to use, the System, except as expressly authorized in this agreement. You also agree not to, and not to authorize or permit others to, copy, modify, adapt, sell, license, create derivative works from, or otherwise transfer all or any part of the System or any user data relating thereto. You further agree that you will not, and will not authorize or permit others to, reverse engineer, reverse assemble, reverse compile, decompile, disassemble, or otherwise translate all or any part of the system, nor will you use or authorize or permit others to use any mechanical, electronic or other methods to trace, decompile, disassemble or identify the source code or data model of the system or any part thereof.

   

  5. Means and Scope of Access. At all times, AlturaMSO reserves the right in its sole discretion to determine, change, suspend, remove and restrict the means and scope of access to the System, including but not limited to, requiring the use of or changing user names and passwords, limiting the duration of access, and restricting the scope of access to specific or limited portions of the System, in each case without notice or liability to you or any others. 

   

  6. Security of Access. You are solely responsible for the security of the user name and password assigned to you. You agree at all times: (i) to hold in trust and confidence your user name, passwords, logins, keys, and any other device or information provided to you to enable your access to and use of the System; (ii) not to authorize or permit any other person to access, know, or use your user name, password, or any other device or information that enables you to access the System; (iii) not to access the System on behalf of any others who are not authorized to access the System; and (iv) to immediately report to AlturaMSO any theft, loss, misuse, compromise, or other incident relating to the security of the System.

   

  7. System Inputs. You acknowledge and agree that during the term of this agreement, if you are authorized to input any information into the System, or provide AlturaMSO or its designee with information to be inputted into, or otherwise used in conjunction with the System, then you agree to assume sole and complete responsibility for the accuracy, completeness, reliability, quality and timeliness of all information that is input by you into the System, or is provided by you to AlturaMSO or its designee to be included in the System, including user names, login, password, and security information, and for promptly reporting to AlturaMSO any and all errors, omissions and updates to the foregoing (the foregoing information is collectively referred to as the "User Data"). In addition, you agree that you will not, and will not authorize or permit others to, input, import, export or transmit to the System, any User Data that: (i) constitutes or encourages the commission of a criminal offense, gives rise to civil liability or violates any local, state, federal or international law, statute, ordinance or regulation; (ii) infringes on any AlturaMSO or non-party copyright, patent, trademark, trade secret or other proprietary rights or rights of publicity or privacy; (iii) is defamatory, trade libelous, unlawfully threatening or unlawfully harassing; (iv) is obscene or pornographic, sexually explicit or contains child pornography; (v) violates any laws regarding confidentiality of patient-related information; (vi) constitutes unfair competition or false advertising; (vii) interferes with, disrupts or otherwise disturbs the colloquy, dialogue, conversations or communications of other users; or (viii) contains any viruses, Trojan horses, worms, time bombs, cancelbots or other computer programming routines that are intended to damage, detrimentally interfere with, surreptitiously intercept or expropriate any system, data or personal information.

   

  8. Third Party Systems and Services. You acknowledge and agree that the System may include software and information, or links to web sites, software and information provided by third parties, and that AlturaMSO is not responsible for examining, evaluating or assuring the functionality, availability or content of any such third-party systems, web sites or information. AlturaMSO does not warrant or endorse and does not assume and will not have any liability or responsibility for, any third-party systems, web sites, or information, or for any other materials, products, or services of third parties. Links to other systems, web sites and information are provided solely as a convenience to you. You agree that you will not use any third-party materials in a manner that would infringe or violate the rights of any other party, and that AlturaMSO is not in any way responsible for any such use by you.

   

  9. Regulatory Compliance. You agree at all times during the term of this agreement, to use the System, and to perform your obligations under this agreement, in compliance with all federal, state and local laws and regulations applicable to the provision of health care services or payment for such services, including in particular, but without limitation, laws relating to confidentiality of patient- related information, and laws governing billing and collecting payments from users and arrangements between providers and sources of referrals of patients, medical services or supplies. Without limiting the foregoing, you agree to assume sole and complete responsibility for ensuring that your use of the System is at all times during the term of this agreement in compliance with all applicable federal and state security and privacy rules, laws, regulations and requirements, including but not limited to the federal Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act of 2009 and the regulations promulgated that relate to the security and privacy of individually identifiable health information, as such laws and regulations may be amended or replaced from time to time.

   

  10. Term and Termination. This agreement shall become effective on the date that you indicate your agreement, and shall continue thereafter until terminated as provided herein. Either party may terminate this agreement at any time, without cause, and with or without notice. In addition, AlturaMSO may terminate this agreement if you engage in any activity or practice that constitutes a violation of this agreement. Upon the termination of this agreement, you shall cease all access to and use of the System, and shall delete all copies of user names, passwords, keys and all other devices that enable you to access or use the System, including but not limited to, all cookies and caches containing information obtained from or relating to your access to and use of the System. Notwithstanding termination of this agreement and your access to the System, your obligations to maintain the confidentiality of System information and User Data will continue indefinitely.

   

  11. DISCLAIMER OF WARRANTIES. ALTURAMSO EXPRESSLY DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, ARISING IN CONNECTION WITH THIS AGREEMENT, OR ITS IMPLEMENTATION, OR ARISING OUT OF A COURSE OF PERFORMANCE, DEALING, OR TRADE USAGE, INCLUDING, WITHOUT LIMITATION, ANY WARRANTIES OF TITLE, NONINFRINGEMENT, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE OR UNINTERRUPTED OR ERROR-FREE USE OR OPERATION OF THE SYSTEM. YOU ACKNOWLEDGE THAT THE SYSTEM IS PROVIDED ON AN "AS IS" AND "AS AVAILABLE" BASIS.

   

  12. LIMITED REMEDIES. TO THE MAXIMUM EXTENT PERMITTED BY LAW, ALTURAMSO SHALL IN NO EVENT BE HELD LIABLE FOR ANY SPECIAL, CONSEQUENTIAL, INCIDENTAL, INDIRECT OR PUNITIVE DAMAGES (INCLUDING DAMAGES DERIVED FROM THE LOSS OF EARNINGS, PROFITS OR GOODWILL OR FROM INCREASED EXPENSES OR COSTS, FORESEEABLE OR UNFORESEEABLE), THAT MAY BE INCURRED OR SUFFERED BY YOU OR ANY OTHER PERSON, WHETHER UNDER THE LAWS OF CONTRACT, STRICT LIABILITY, TORT OR OTHERWISE, AS A RESULT OF THE USE OR INABILITY TO USE THE SYSTEM. THE LIMITATIONS CONTAINED IN THIS SECTION APPLY TO ALL CAUSES OF ACTION IN THE AGGREGATE, WHETHER BASED IN CONTRACT, TORT (INCLUDING NEGLIGENCE) OR ANY OTHER LEGAL THEORY (INCLUDING STRICT LIABILITY).

   

  13. Assignment. You agree not to assign any of its rights or delegate any of its duties under this agreement, in whole or in part, by operation of law or otherwise, except with the prior written consent of AlturaMSO, which consent may withheld, conditioned or delayed, for any reason or no reason at all.

   

  14. General Terms of Agreement.This agreement constitutes the entire agreement between the parties with respect to access and use of the System as provided hereunder, and supersedes all prior or contemporaneous understandings regarding such subject matter, except for such policies, procedures and terms of use implemented by AlturaMSO and to which you agree by using the System. No amendment to or modification of this agreement will be binding unless made in writing and signed by AlturaMSO. This agreement will be governed by and construed in accordance with the laws of the State of California. In the event an ambiguity or question of intent or interpretation arises, this agreement shall be construed as if drafted jointly by the parties hereto and no presumption or burden of proof shall arise favoring or disfavoring any party by virtue of the authorship of any of the provisions of this agreement. No waiver of any requirement of this agreement will be effective unless made in writing and signed by an authorized representative of AlturaMSO. The waiver by AlturaMSO of any failure to comply with this agreement will not operate or be interpreted as a waiver of any other or subsequent failure to comply. No rights are granted herein by implication.

   

  You acknowledge that you have read this agreement and understand and agree to be bound by its terms and conditions. Checking the box below and clicking on the "Submit" button below indicates that you have read, completely understand, and agree to all of the requirements of this agreement.