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Dd 2875 nov 2024 Form: What You Should Know

SUMMARY: This form identifies a person as a user of an HHS-managed system. This form must be provided to a system administrator when required to provide system usage information under the System Authorizations of Personal Health Information Act. APPLICATION INFORMATION: 1. Name: 2. Date of Birth: 3. SSN: 4. Home Phone: 5. Home Postal Code: 6. Home Phone Subscription: 7. Work Phone: 8. Work Phone Subscription: 9. Relationship to Applicant 10. Date/Time of Request: 11. Signature: 12. Signature, Date. (a) The name of the person being requested access to the system; (b) The address to which access is requested; (c) The name of the person requesting access to the system (for identification purposes); and (d) The date the person requested the access. PRINCIPAL REQUIREMENTS: 1. Applicants must register with an HHS system on which they will be using the system access to verify their identity and, in the case of multiple requests to the same system, to allow expedited access by multiple users, as necessary. 2. An applicant may use the system for a number of purposes: 1. To verify identity and medical address when needed, such as when a patient is being managed by a health plan; 2. To access information for a lawful purpose, such as when a child is enrolled in school; 3. To obtain information from Federal, State, or local Government agencies for reporting purposes; 4. For other lawful purposes, such as law enforcement activities; 5. To obtain health information on themselves (such as for use in determining financial eligibility of children that need a health subsidy). 5. If a system for which an individual needs system access is under the control of another entity, such as when accessing a health or employment information system, the requesting party must obtain the written authorization of the owner or operator of the system before using the individual's name, SSN, and/or information in any form. 6. A waiver of the foregoing procedures is available for individuals with a compelling, documented need as determined by the ITS. 7. A valid government issued photo ID is required for obtaining access to systems for which an applicant does not have a valid government issued photo ID. APPENDIX: 1.

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