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I, the undersigned, hereby agree to comply with all rules and regulations governing the Arkansas Immunization Information System (DBA Arkansas WebIZ) according to Act 432 of 1995 and Act 869 of 1997 as amended.

I agree that information received from the Arkansas Immunization Information System will meet the standards governing confidentiality as prescribed by the Arkansas Department of Health, which includes, but is not limited to, the following:

• Information will not be released to a third party without written permission of the patient or guardian, and submission of a copy of said permission to the Arkansas Department of Health Immunizations Section.
• Information will be kept secure, according to the standards required by the Arkansas Department of Health, to prevent unauthorized access to the system.
• Information will be used in strict accordance with reasons described in the written request for access.

I agree to abide by the protocols, security measures, and training required by the Arkansas Department of Health, including, but not limited to, the following:

• I will never share the details of my user name or password with any other individual, including Arkansas Department of Health personnel.
• I understand that by accessing the Arkansas Immunization Information System (Arkansas WebIZ) my activity within the system is tracked and stored via a permanent built-in audit device, and that this information can never be altered or deleted.
• I understand that Arkansas State Law dictates that an immunization record is determined to be part of a patient’s official medical record, and that changing/altering an immunization record in any means without sufficient supporting evidence, recording false information on an immunization record, or participating in any other activity that detracts from the ability to identify the patient of record, is against state and federal laws.
• I understand that any malicious and/or illegal activity, as defined by the Health Insurance Portability and Accountability Act (HIPPA)(42 USC 1320d-6) and the Health Information Technology for Economic and Clinical Health Act (HITECH), performed under my username within the Arkansas WebIZ system will result in an immediate suspension of my account.
• I understand that I, solely, am responsible for any malicious or illegal activity, or any activity that deviates from activity deemed appropriate by the Arkansas Department of Health, performed under my username, whether by me or an unauthorized user of my account.

I agree to use the Arkansas Department of Health provided HL7 specifications (if applicable) to ensure the following:

• The HL7 interface is current and updated within 30 days of any Arkansas Department of Health modifications, updates, or recommendations.
• To exchange immunization records at a minimum time interval defined by the Arkansas Department of Health here:
..o For providers participating in the Vaccination for Children (VFC) program, immunization records must be exchanged with Arkansas WebIZ on the same date in which the vaccination was administered.
..o For non-VFC providers, immunization records must be exchanged with Arkansas WebIZ weekly with the understanding that the Arkansas Department of Health recommends a daily transmittal of records.
• To correct and resubmit rejected immunization records and process any and all error messages received.
• To make adjustments to the interface or correction of immunization records as emphasized in the Arkansas Department of Health’s data quality monitoring and reporting document.
• To ensure the overall quality and integrity of the data our organization submits into the Arkansas Immunization Information System (Arkansas WebIZ).

I understand that any wrongful disclosure of individually identifiable health information will be considered a violation of the Health Insurance Portability and Accountability Act (HIPAA) (42 USC 1320d-6). I further understand that the level of violation and associated penalty is determined by the Health Information Technology for Economic and Clinical Health Act (HITECH) to include the following:

• A Tier A violation constitutes a violation in which the offender did not realize (s)he violated HIPAA and would have handled the matter differently had (s)he had. This results in a $100 for each violation, and the total imposed for such violations cannot exceed $25,000 for the calendar year.
• A Tier B violation is a violation due to reasonable cause, but not “willful neglect.” The result is a $1,000 fine for each violation, and the fines cannot exceed $100,000 for the calendar year.
• A Tier C violation is a violation due to willful neglect that the organization ultimately corrected. The result is $10,000 fine for each violation, and the fines cannot exceed $250,000 for the calendar year.
• A Tier D violation is for a violation of willful neglect that the organization/individual did not correct. The result is a $50,000 fine for each violation, and the fines cannot exceed $1,500,000 for the calendar year.

I also understand that the HITECH Act gives the Arkansas State Attorney General the ability to levy fines and seek legal fees from covered entities on behalf of victims. I understand that wrongful disclosure can result in imprisonment for not more than 10 years in addition to the aforementioned fines. Further, I understand that Wrongful disclosures may also result in criminal sanctions from the State of Arkansas, including fines up to $500.00 or imprisonment not exceeding one (1) month, or both. In addition, civil penalties may also be administered on the state level by the State Board of Health, allowing for fines up to $1,000 per violation.

I understand that being granted access to the Arkansas Immunization Information System (Arkansas WebIZ) does not commit the Arkansas Department of Health to any expense.

I understand that non-compliance with any section of this user agreement will result in an immediate loss of access to the Arkansas Immunization Information System (WebIZ) for both myself and the organization for which I represent.

I certify that I have read, Reviewed, and thoroughly understand the terms and conditions as outlined and explained in this user agreement for access to the Arkansas Immunization Information System.

BY CHECKING THE BOX AND TYPING MY NAME TO THIS DOCUMENT I CERTIFY THAT I HAVE READ AND UNDERSTAND ALL OF THE STATEMENTS IN THIS APPLICATION FOR ACCESS TO THE ARKANSAS IMMUNIZATION INFORMATION SYSTEM. I FURTHER CERTIFY THAT I UNDERSTAND THAT ANY DEVIATION FROM THIS AGREEMENT WILL RESULT IN THE IMMEDIATE SUSPENSION OF MY USER ACCOUNT, AND DEPENDING ON THE SEVERITY OF THE OFFENSE, THE SUSPENSION OF THE ORGANIZATION THAT I REPRESENT. I UNDERSTAND THAT THE SUSPENSION OF AN ORGANIZATION-LEVEL ACCOUNT COULD HAVE A DIRECT IMPACT ON THE ORGANIZATION’S ABILITY TO COMPLETE AND/OR ATTEST FOR MEANINGFUL USE AND/OR OTHER INITIATIVES. I UNDERSTAND THAT BY TYPING MY NAME BELOW HOLDS THE SAME LEGAL WEIGHT AS MY HAND-WRITTEN SIGNATURE.
I Accept and Affix My Signature