Health Care Practitioners
MyPlanTools Access Request Form

This form should be used when you are requesting access for your facility to our online portal, MyPlanTools. 

This form should not be used if your facility already has access and you wish to add a user. 

 

* Required Field

† This request should be made by a Company Officer or authorized Management Personnel on behalf of the Provider.
The following individual(s) are authorized to have “Manager” account access. This / These individual(s) is / are authorized to request access be added, changed, or disabled for other individuals under the Facility Name / Tax ID. This account access will also allow the individual to have access to patient information.

If the Provider listed in this application (“Provider”) is granted access to MyPlanTools the following conditions apply:


Access to MyPlanTools shall not be construed as conferring any license to MyPlanTools or any information contained in and / or displayed therein to Provider. Provider acknowledges and agrees that information contained in and / or displayed via MyPlanTools may be considered Protected Health Information (“PHI”), as defined by the Health Insurance Portability and Accountability Act of 1996 (and regulations thereunder as amended from time to time) (“HIPAA”). As such, Provider agrees to abide by the Privacy and Security Rules of HIPAA and any other applicable laws and regulations.


Provider agrees to limit access to MyPlanTools and information contained and / or displayed therein in accordance with HIPAA, which includes but is not limited to creating and assigning User IDs and passwords only for those end users who are authorized to use, access, or disclose PHI, and limiting use of PHI to the “minimum necessary” needed to complete work. Provider agrees to timely terminate access to MyPlanTools when an end user resigns or changes job duties that no longer require the end user to access MyPlanTools. Timely termination is termination within two (2) business days after one of the aforementioned events occurs. If there is a breach or suspected breach of a User ID or password, Provider and / or the end user must notify their Provider Coordinator as soon as practicably possible but no later than two (2) business days after discovery. Provider is responsible for any and all breaches of security resulting from end user access to MyPlanTools.


We reserve the right to terminate Provider’s and / or any end user associated with Provider’s access to MyPlanTools at any time.

The information contained within this form will be applied to all applicable contracts with Unity Health Plans Insurance Corporation, Quartz Health Solutions, Inc. f/k/a SPWI TPA, Inc. d/b/a Quartz, and Gundersen Health Plan, Inc.