HEALTH COMMERCE SYSTEM (HCS) HOSPITAL APPLICATION ACCESS FORM

HEALTH COMMERCE SYSTEM (HCS)

HOSPITAL APPLICATION ACCESS FORM

DIVISION OF FINANCE AND RATE SETTING

One Commerce Plaza – Room 1405, 99 Washington Avenue, Albany, NY 12210

***Please scan and e-mail completed form to: hospFFSunit@health.ny.gov***

SECTION I (HCS User & Facility Information):

Name (Please Print): _____________________________________________________________

Title: ___________________________________________________________________________

HCS User ID: _______________________________________

Hospital Name: ___________________________________________________________________

Operating Certificate Number: _______________________________________________________

Street Address: __________________________________________________________________

City: _________________________________________ State: ______________ Zip: ____________

Telephone: (     ) _________________________________________

E-Mail Address: ___________________________________________________________________

Signature: _____________________________________ Date: _____________________________

) ss.: On the _________ day of __________ in the year ______________ before me, the undersigned, personally appeared to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, that by his/her signature on the instrument, the individual executed the instrument, and that such individual made such appearance before the undersigned in the ____________________________ (insert the city or other political subdivision and the state or country or other place the acknowledgement was taken.)

Notary Signature and Stamp on this line: ________________________________________________

SECTION II (AUTHORIZATION TO ACCESS HOSPITAL DATA):

HCS Coordinator Name (Please Print): _________________________________________________

Signature: _____________________________________ Date: _____________________________

) ss.: On the day of in the year before me, the undersigned, personally appeared to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, that by his/her signature on the instrument, the individual executed the instrument, and that such individual made such appearance before the undersigned in the (insert the city or other political subdivision and the state or country or other place the acknowledgement was taken.)

Notary Signature and Stamp on this line: ________________________________________________

Name (Please Print): _______________________________________________________________

HCS User ID: _____________________________________________________________________

Hospital Name: ___________________________________________________________________

Operating Certificate Number: _______________________________________________________

SECTION III (REQUESTED ACCESS TO APPLICATIONS):

Note: If application is not marked with an "X" for YES, it will be considered NO for Access.

  YES NO
HOSPITAL APPLICATIONS:
Note: if "Yes" is marked, access will automatically be granted to all of the following applications (or none if "No" is marked):
  1. Healthcare Financial Data Gateway, which includes:
    • Budgeted Capital Report Software
    • Disproportionate Share (DSH) Audits
    • Indigent Care Calculation
    • Inpatient Reform Rates
    • Institutional Cost Report (ICR) Base Year Information
    • Institutional Cost Report (ICR) Audit Files
    • Outpatient Rate Reports
    • Outpatient Reform Rates
   
  1. Institutional Cost Report (ICR) – Instructions/Submissions
   
HOSPITAL-BASED NURSING HOME APPLICATIONS:
  1. RHCF-2 (only for facilities with hospital-based nursing homes)
   

Note: User must already have an HCS account established before access may be granted.

INSTRUCTIONS:

SECTION I (HCS User & Facility Information):

Name: Name of the individual who has an HCS account and is requesting access to the Division´s HCS hospital applications.

Title: Official title of the individual within the organization which he/she is employed.

HCS User ID: The personal HCS User Id of the individual requesting access to the hospital applications. The user MUST ALREADY have an HCS Account before completing this form to request access to the applications. Contact your HCS Coordinator or the Commerce Accounts Management Unit (1-866-529-1890) if you need assistance with getting an account established.

Hospital Name: Name of the facility or legal entity responsible for the submission and/or retrieval of public health data using the HCS that the user is requesting access for.

Operating Certificate Number: Operating Certificate Number of the hospital (Ex.1112222H). Street Address: Number and street location (or box number) of HCS user´s place of employment. City, State, Zip Code: City, State and Zip Code of HCS user´s place of employment.

Telephone Number: Office telephone number, including area code, where the HCS user can be reached.

E-mail Address: Complete e-mail address of HCS user requesting access. It is importation that the user has this same email address established within the HCS so that they may receive notifications regarding publications and other notifications regarding the rates, cost reports, etc.

Signature & Date: A notarized official signature of the HCS user requesting access and the date of signing.


SECTION II (Authorization to Access Hospital Data):

HCS Coordinator Name: Name of the HCS Coordinator for the hospital stated in Section I (please print name).

Signature & Date: A notarized official signature of the HCS Coordinator from the hospital the HCS user is requesting access for and the date of signing.

Name, HCS User ID, Hospital Name and Operating Certificate Number: same as Section I.


SECTION III (Requested Access to Applications):

Hospital Applications: Place an "X" in either "YES" or "NO" for the applications that the User in Section I is requesting access. If nothing is marked for an application, access will not be granted for that application.

Please scan and e-mail completed form to: hospFFSunit@health.ny.gov. It is not necessary to mail the original copy.

HOSPACCESS 10/2018