As a benefit of being a Physician Society Member, you can sign up for resource applications. Please complete the form below. If you are not a Physician Society Member, please apply for membership.
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Resource Applications Agreement
In connection with your professional relationship (Employee, Workforce Member, or Physician) with Memorial Health Services (“MemorialCare”), MemorialCare is granting you permission to access certain of its systems (the “Systems”) remotely. This permission is subject to your strict adherence to the restrictions and limitations described below. The ability to access the Systems remotely is a privilege, not a right, which may be modified or revoked by MemorialCare at any time, without cause or notice.
Workplace Safety. You are responsible for regularly checking your remote workspace to ensure it complies with all health and safety requirements, including appropriate workstation configuration for reduction of repetitive stress and other similar injuries. MemorialCare does not control and has no responsibility or liability for ensuring the health and safety of the location from which you remotely access the Systems.
Use of Remote Access Technology. You must perform your work using only a computer provided by MemorialCare or a personal computer that meets the technical requirement defined in Appendix A. All remote access must be made using only those procedures specified by MemorialCare and only for the purposes specifically authorized by MemorialCare. You are responsible for ensuring only MemorialCare authorized personnel (e.g., no family members, office staff) will have access to (i) MemorialCare provided computers, (ii) confidential and proprietary information, or (iii) MemorialCare system access procedures. In the event you become aware of any unauthorized access to the Systems or MemorialCare’s data or confidential information, you must immediately notify the MemorialCare Service Desk at 562-933-9450. You may not sell or otherwise dispose of any computer, laptop, or other equipment provided by MemorialCare. You must at all times ensure that access to the equipment is limited as described in this provision. In particular, you may not leave unattended a computer remotely connected to the Systems (e.g., go to lunch with your computer logged into our systems). You may not copy MemorialCare confidential or proprietary information to any form of Removable Media (defined below). In the event MemorialCare confidential or proprietary information is reduced to printed form (e.g., by a printer or fax), all copies of such printouts must be returned to MemorialCare. Papers containing MemorialCare confidential or proprietary information that are no longer needed may not be disposed of at your remote work location. All such papers must be returned to MemorialCare for proper destruction.
For purposes of this Agreement, “Removable Media” means portable or removable hard disks, floppy disks, USB memory drives, zip disks, optical disks, CDs, DVDs, digital film, memory cards (e.g., Secure Digital (SD), Memory Sticks (MS), CompactFlash (CF), SmartMedia (SM), MultiMediaCard (MMC), and xD-Picture Card (xD)), magnetic tape, and all other removable data storage media.
Work Site Inspections. On reasonable notice, you agree to permit MemorialCare to inspect the location and computers from which you access the Systems remotely.
Compliance with all Applicable Policies. Although you may be authorized to work at a remote work location, you will still be obligated to comply with all applicable MemorialCare policies and procedures, including those relating to information security, confidentiality, privacy, and use of information technology.
Supporting and Defining Policy. At all times your actions and use of MemorialCare computing resources must be consistent with MemorialCare policy, specifically, “Policy Regarding Responsible use of Technology Resources and Information.” A copy is attached to this participation agreement.
I certify that my identification number and password represent my signature and as such, carry all the ethical and legal implications of a written signature. I will not disclose my electronic signature password to any person or permit another person to use it. I further agree to use electronic signature for all my dictated reports.
I understand that in selecting "Yes" to this permission form I am acknowledging I have read, understand, and agree to be bound by the restrictions and limitations described above.
I certify that the information provided above is true and correct. I agree that MemorialCare, its representatives, and any individuals or entities providing information to MemorialCare in good faith shall not be liable to, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this document. I hereby give permission to release to this MemorialCare information about my medical practice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the content of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in this form to discuss any information regarding this case with MemorialCare.
For additional information about the MemorialCare Physician Society or for questions about this form, please call 866-405-EPIC (3742).
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