ADSI Customer Authorization - Overnight Oximetry...
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ADSI – IDTF West 1900 S Norfolk Street, # 350 San Mateo, CA 94403-1171 Phone: (877) 566-7815 ADSI Corporate 6125 Sherwin Drive Port Richey, FL 34668-6751 Phone: (352) 293-2810 ADSI Customer Authorization Consent to Share Information, including Patient Information to Brightree Database As you know, ADSI has been built to be able to exchange data to and from your database in the Brightree BSP Services solution. It is our policy and Brightree’s policy to obtain written consent from each of our customers before data is transferred between vendors. We have a business associate agreement in place with you, and we have been informed by Brightree LLC that they also have a business associate agreement in place with you for the protection of that information. Please complete the required fields below and return this form authorizing Brightree to pass your information from the Brightree BSP Services to the ADSI Solution. By signing below, I hereby grant my consent to the passage of data between the Brightree BSP Services and the ADSI Solution. Company Information Company Name: _______________________________________________________________________ Brightree Alias/Nickname (The phrase after the “@” symbol): __________________________________ Employee Name: ____________________________________ Title: ______________________________ Email: _______________________________________________________________________________ Phone: ____________________ Fax: ____________________ Branch ID(s)# (BranchKeyValue): __________________________________________________________ Signature: ___________________________________________________ Date: _______________ ** Please note that all above fields are required.
Transcript of ADSI Customer Authorization - Overnight Oximetry...
ADSI – IDTF West 1900 S Norfolk Street, # 350 San Mateo, CA 94403-1171
Phone: (877) 566-7815
ADSI Corporate 6125 Sherwin Drive Port Richey, FL 34668-6751 Phone: (352) 293-2810
ADSI Customer Authorization Consent to Share Information, including Patient Information to Brightree Database
As you know, ADSI has been built to be able to exchange data to and from your database in the Brightree BSP Services solution. It is our policy and Brightree’s policy to obtain written consent from each of our customers before data is transferred between vendors. We have a business associate agreement in place with you, and we have been informed by Brightree LLC that they also have a business associate agreement in place with you for the protection of that information. Please complete the required fields below and return this form authorizing Brightree to pass your information from the Brightree BSP Services to the ADSI Solution. By signing below, I hereby grant my consent to the passage of data between the Brightree BSP Services and the ADSI Solution.
Company Information
Company Name: _______________________________________________________________________ Brightree Alias/Nickname (The phrase after the “@” symbol): __________________________________ Employee Name: ____________________________________ Title: ______________________________ Email: _______________________________________________________________________________ Phone: ____________________ Fax: ____________________ Branch ID(s)# (BranchKeyValue): __________________________________________________________
Signature: ___________________________________________________ Date: _______________
** Please note that all above fields are required.
