ELECTRONIC PRIOR CLAIMS SYSTEM ACCESS AGREEMENT The purpose of this agreement is to provide access for an insurer, an insurer's designated agent, an attorney, a medical provider or an authorized state employee to current or prior workers' compensation claim information held in the Employment Relation Division's ("Division") workers' compensation database. Access will be allowed when an insurer is at risk on a claim, when an insurer is conducting a fraud investigation on a particular claim, when an attorney has an approved fee agreement for an injured worker, when a medical provider requires payer information or when a state employee has been authorized by statute or a signed release by the workers' compensation claimant. The parties listed above are hereinafter referred to as "Entity". In consideration of obtaining direct access to certain claim information through the Division's Electronic Prior Claims (EPC) system, the Entity's signatory to this agreement agrees to the following: 1. The information obtained from the Division's workers' compensation database must remain confidential and may not be disclosed to any third party except to the extent necessary for determining claim liability or fraud investigation. Users of information obtained from the workers' compensation database are liable for damages arising from misuse or unlawful dissemination of claim information. Claim history information is limited to: claimant's name; last 4 digits of the claimant's identification number; claim number; date of injury; agency claim number; body part involved; and name and address of the insurer and claim administrator on each claim filed by that claimant as shown in the Montana workers' compensation database system. Upon approval and execution of this agreement, the Division will assign a unique login identification and password to the individual(s) identified by the Entity signing this agreement. The login identification and password must be stored in a secure location accessible by authorized persons only. Login IDs and passwords must not be shared with co-workers or future employees that may replace the designated user. The Division must be promptly notified if an individual no longer needs access to the EPC. Due to the very nature of technology, the Division implies no guarantee that this system will be accessible 100 percent of the time. The Division's workers' compensation database contains information on Montana workers' compensation claims reported to the Division with an injury date later than July 1, 1981. This information is shown as it was reported to the Division. Due to reporting time requirements and late or non-reporting, not all claims may be included in the database. Claim information is updated nightly Monday through Friday. 2. 3. 4. 5. 9/20/2013 ­ dje Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. The designated representative below is the individual responsible for executing the EPC agreement, adherence to the terms of this agreement and to authorize and maintain the approved users. Designated Representative Information Name of Organization: Name of Contact: Title: Phone number: Fax number: E-mail address: Mailing address: 7. 8. The designated representative will complete an EPC User Profile form for each EPC user. This agreement becomes effective upon receipt by the Division of the signed agreement and verification of access requirements. To modify or terminate this agreement, written notification is required within 14 days of the event. The parties below have executed this Agreement and agree to all conditions stated therein: _____________________________________ Designated Representative Signature _________________ Date _____________________________________ Division Representative Signature _________________ Date **Please return the form upon completion to the following:** Attorneys: return to Nikki Hartman Fax (406) 444-4140 Tel. (406) 444-7751 All Others: return to Mona Hylton Fax (406) 444-4140 Tel. (406) 444-6525 9/20/2013 ­ dje Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com EPC USER PROFILE(S) User Name: Name of Organization: Phone number: E-mail address: I have read the Electronic Prior Claims Access Agreement and agree to all conditions contained therein. ___________________________ _________________ User's Signature* Date DIVISION USE ONLY ____________________ Login ID _______________________ Password User Name: Name of Organization: Phone number: E-mail address: I have read the Electronic Prior Claims Access Agreement and agree to all conditions contained therein. ___________________________ _________________ User's Signature* Date DIVISION USE ONLY ____________________ Login ID _______________________ Password User Name: Name of Organization: Phone number: E-mail address: I have read the Electronic Prior Claims Access Agreement and agree to all conditions contained therein. ___________________________ User's Signature* _________________ Date DIVISION USE ONLY ____________________ Login ID _______________________ Password *Not valid unless signed by designated representative below. The above individual(s) is (are) approved users of the EPC for ___________________________ . (Name of Organization) __________________________________________ Signature of Entity's Designated Representative ____________________ Date **Please return the form upon completion to the following:** Attorneys: return to Nikki Hartman Fax (406) 444-4140 Tel. (406) 444-7751 All Others: return to Mona Hylton Fax (406) 444-4140 Tel. (406) 444-6525 9/20/2013 ­ dje Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com