Information Sharing Agreement WA Imms

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Page 8 of 8 If you have a disability and need this document in another format, please call 1 -800-525-0127 (711-TTY relay). DOH 348-576 November 2017 ATTACHMENT C Washington State Immunization Information System System User Access Account for Exchange of Immunization Data Provider/Plan Name_______________________________ Contract # ______________ This worksheet is to request user accounts to access IIS Immunization Data under the above Information Sharing Agreement. Make additional copies of this form if needed. Fill in the requested information for each principal or employee who will need access to IIS Immunization Data, then fax the form to 360-263-3590. Each person must create a Login ID of all letters, all numbers, or a combination of letters and numbers AT LEAST four characters long (but can be longer). Login IDs are not case sensitive. IIS will provide a temporary password for each user. The system will prompt for a new password upon logging in the first time. Questions? Please contact our Help Desk at 1-800-325-5599 or via email atWAIISHelpDesk@doh.wa.gov. Login ID:_____________________________ (at least 4 characters) Office Phone (____) _____ – _______ Ext._______ Office Email:_______________________________________________ Credentials, if any:____________ (e.g., MA, RN) First Name:__________________________________ Last Name:________________________________________ Clinic Site(s): _____________________________________________________________________________________ Does user float between more than one clinic? ___yes ___no Does the user administer vaccines? ___yes ___no Login ID:_____________________________ (at least 4 characters) Office Phone (____) _____ – _______ Ext._______ Office Email:_______________________________________________ Credentials, if any:____________ (e.g., MA, RN) First Name:__________________________________ Last Name:________________________________________ Clinic Site(s): _____________________________________________________________________________________ Does user float between more than one clinic? ___yes ___no Does the user administer vaccines? ___yes ___no Login ID:_____________________________ (at least 4 characters) Office Phone (____) _____ – _______ Ext._______ Office Email:_______________________________________________ Credentials, if any:____________ (e.g., MA, RN) First Name:__________________________________ Last Name:________________________________________ Clinic Site(s): _____________________________________________________________________________________ Does user float between more than one clinic? ___yes ___no Does the user administer vaccines? ___yes ___no