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Physician/Provider Information Systems Computer Agreement

I, ___________________________________ agree to the following terms of use:

• This computer is provided for EMR access and direct Clinic business related internet access only, not personal use. • Physician may not store personal documents or load private software on this computer. Any data from personal use will not be stored or recovered by the (Clinic Name) Information Systems department. In the case of a computer or hard drive failure, only the original settings and Clinic approved programs will be restored. Loss of personal data is not the responsibility of the (Clinic Name). • For internet access outside of the Clinic, it is the responsibility of the user. A high speed DSL or cable modem is recommended. • Mobile computer may be taken off-site for use by the provider for Clinic related work only. The provider is responsible for the proper transportation, charging and security of the mobile computer while it is in their care. HIPAA privacy and security guidelines apply at all times. • In the event that your computer is lost or stolen. You are responsible for reporting the lost to (Clinic IT Department Information) immediately so that appropriate security measures can be taken. • The computer is the property of the (Clinic Name) and must be returned at the end of employment. • IT support expenses that are incurred for failure to follow this policy will result in a direct expense to your cost center. • Your computer has been purchased with a limited warrantee that covers manufacturer’s defects. Unlimited warrantees which cover replacement in the event of drops or other incidental damage may be purchased for an additional fee to you.

Signed: __________________________________________________ Date: _______________

Print Name: ___________________________________________________________________