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Request for Access / Non-Disclosure

“My AultCare” is a secure, web-based application. It requires a user name and password to access. By requesting a user name and password, you acknowledge that you have the authority to request such access. “My AultCare” is intended to assist AultCare's clients with their health care operations or payment activities, such as eligibility verification or claims submission. It is provided as a service to AultCare's clients. Misuse of this privilege may result in the revocation of your ability to access the “My AultCare”; application.

By using “My AultCare” you agree that “My AultCare” provides access to confidential protected health information, and that you will maintain this confidentiality in accordance with all applicable state and federal laws. You further agree that you will not share your username, password, or any information learned from this application, and that you will notify AultCare if you have reason to believe someone has learned your username or password. Furthermore, you agree that your duty to maintain the confidentiality of protected health information maintained on the “My AultCare” database survives the termination of your relationship with AultCare .

To access “My AultCare” go to www.aultcare.com .
The terms of this non-disclosure agreement also apply to using the AultCare FTP site which requires a separate login and password.

(typing your name will represent your signature)
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