The IMS-01 form is a User ID and System Access Request Form used by the New York State Office for People With Developmental Disabilities (OPWDD). This form allows users to request access to OPWDD applications, modify their roles, or revoke access as needed. To ensure compliance and avoid rejection, users must fill out the form accurately and submit it according to the provided guidelines.
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The IMS-01 form, officially known as the User ID and System Access Request Form, is an essential tool for individuals seeking access to the New York State Office for People With Developmental Disabilities (OPWDD) systems. This form, revised as of January 28, 2019, is designed to streamline the process of requesting, modifying, or revoking user access to OPWDD applications. It consists of several sections, each serving a specific purpose. In the first section, users provide their personal and agency information, ensuring that all details are typed and accurate to avoid any processing delays. The second section focuses on the type of access being requested, whether it's to grant new access, modify existing roles, or revoke access altogether. A crucial part of the form is the Statement of Use, where users acknowledge their responsibilities and the limitations of their access, emphasizing the importance of confidentiality and compliance with relevant laws. Additionally, the form requires executive approval, ensuring that all access requests are authorized by the appropriate agency leadership. Finally, there’s a section for secure application authorizer approval, applicable only for certain requests. Understanding the nuances of this form is vital for ensuring compliance and safeguarding sensitive information within the OPWDD systems.
NYS Office for People With Developmental Disabilities
Form IMS-01 (Revised 01/28/2019)
User ID and System Access Request Form (External)
If unable to use Adobe Reader XI to complete form, please see page 2 for assistance.
Section 1 - User Information
DO NOT HANDWRITE IN SECTION 1
Agency Name:
First Name:
OPWDD Agency ID:
MI:
Last Name:
Title:
Work Telephone:
Work Address:
Street
City
State
Zip Code
User's Agency E-Mail:
Section 2 - OPWDD User ID & Access Request* DO NOT HANDWRITE IN SECTION 2
OPWDD USER ID Status: Select ONE option from drop down menu
Application Access Request:
Grant
Modify Role Revoke
Please use the below free version of
Adobe Acrobat Reader
to complete the form.
Select ONE application from drop down
Section 3 - Statement of Use To be read and signed by user requesting to USE OPWDD application(s).
Users are responsible for ALL activity performed with their assigned OPWDD User ID. Use is limited to conducting official business involving OPWDD. Any use, authorized or not, constitutes express consent for authorized personnel to monitor, intercept, record, read, copy, access or capture such information for use or disclosure in any manner without additional prior notice. Users have no legitimate expectation of privacy during any use of OPWDD systems. Unauthorized use or attempted unauthorized use is not permitted and may constitute a federal or state crime. Such use may subject you to appropriate disciplinary and/or criminal action. Clinical information, including records that identify or tend to identify individuals served or proposed to be served by OPWDD and its certified providers, is confidential and can only be disclosed in accordance with Mental Hygiene Law Sec. 33.13, HIPAA, and OCS. By signing below, you confirm that you have read, agree, understand the Section 3 "Statement of Use", confirm you have provided your legal (first, middle initial and last) name in section one (1) as well as confirm all information provided in sections 1 , 2 and 3 are correct.
User Signature(DO NOT COMPLETE THIS SECTION IF CLOSE OR REVOKE IS CHOSEN IN SECTION 2)
Date
Section 4 - Executive Approval To be read and signed by Executive Director or authorized designee listed with OPWDD.
Executive Director or authorized designee listed with OPWDD is required to sign, print and date when request of access or any modification /reactivation for section one (1) user. When employee is no longer employed with provider agency, it is the responsibility of the agency to submit a CLOSE request at that time (Sections 1, 2 and 4 ONLY). Failure to do so, may result in a potential HIPAA Violation. Requests for CLOSE OR Revoke of a specific application, is an exception and may be signed by the user, who is currently employed with the provider agency, supervisor OR manager in lieu of the Executive Director, with their name and title printed under their signature. By signing below, you confirm that you are listed with NYSOPWDD as an Executive Director/authorized designee for said agency notated in section 1, you have read, understand and, agree with the above statement and authorize the processing of the request for access made in Section two (2) by the user.
Signature, in section 4, without a printed name will NOT be accepted.
Executive Director Signature (or Authorized Designee signature)
Executive Director printed Name (or Authorized Designee Name and Job Title)
Section 5 - Secure NYS OPWDD Application Authorizer Approval (if required) ONLY authorized OPWDD personnel should
sign in this section. This section is solely intended for users who have chosen an application in section 2 that has "*Note Section 5 Authorizer Required"; If you do NOT see this previously mentioned note in section 2, please do NOT alter this section in any way.
NYS OPWDD Application Authorizer Signature and Printed Name
Form is REJECTED if sections 1 or 2 have ANY handwritten, false and/or missing pertinent information to process the request.
Submit completed form (that does NOT require section 5) or form related inquires to OPWDD IMS - External.Account.Provisioning@opwdd.ny.gov
Submit IR (IRMA) related requests or IRMA related inquiries to OPWDD IMU - Incident.management@opwdd.ny.gov
Submit QI (DQIA) related requests or inquiries to - quality@opwdd.ny.gov
Clear Form
Submit FA - Fire Portal requests or inquires to - Fire.portal.access@opwdd.ny.gov
Print Form
Instructions for Form IMS-01 (Revised 01/28/2019)
User ID and System Access Request Form Instructions
Form is REJECTED if sections 1 or 2 have ANY handwritten, false or missing pertinent information to process the request.
Staff who have NOT officially started working at the agency should NOT request access to the OPWDD systems.
Section 1 - User Information - Do NOT handwrite ANY information.
Please type ALL information requested, do NOT leave any box blank if requesting to use secure OPWDD application(s).
Provide LEGAL First name, middle initial and last name.
If no LEGAL middle name: type an “X”; user must submit their form and confirm they do not legally have a middle name OR middle name begins with an “X”, within the body of the e-mail submission.
Section 2 - OPWDD User ID & Access Request - Do NOT handwrite ANY information.
Part 1 - Select ONE option from the OPWDD User ID Status drop down menu.
OPWDD User ID - User has a User ID with Agency/agency ID provided in section 1. Go to part 2.
I do NOT have an OPWDD User ID* - User does not have an OPWDD User ID in system. Go to part 2.
Additional OPWDD User ID… - User currently has a User ID with a different agency/agency ID. Do NOT enter User ID. Go to part 2. Name Change - User needs to change last name ONLY. No other requests can be made at that time. Go to part 2.
Reactivate Access - 6 months or more since last login (user id account cannot be closed). Go directly to section 3.
Close OPWDD User ID - User no longer employed with agency/no longer need to use User ID account. Go directly to section 4.
*If user requesting more than one account/more than one application, only ONE form should have "I do not have an OPWDD User ID" selected.
Part 2 - Select ONE option from the Application Access Request (grant, modify role OR revoke).
Grant - User needs to gain access to a specific application. Go to part 3.
Modify Role - User needs to change their current role in CHOICES; the user MUST notate their User ID. Go to part 3. Revoke - User still with agency, needs to remove ONE application from User ID account. CLOSE cannot be chosen. Go to part 3.
Part 3 - Select ONE application from the second drop down menu
Select application needed. External Provisioning staff cannot provide the application needed nor a description of the applications.
Double check all information in section 1 and 2, correct issues, if necessary then print the form.
Section 3 - Statement of Use.
User should double check all information in section 1 and 2 if they did not complete those sections. User needs to read, sign and date.
If “Close OPWDD User ID” OR “Revoke” is chosen, Do NOT make any notation/marks/notes in section 3. Do nothing in section 3.
Section 4 - Executive Approval.
Obtain the Executive Director or AUTHORIZED designee listed with OPWDD signature, printed name and date section 4. Submit the completed form to the appropriate unit listed at the bottom of the form; do not submit this page.
Do NOT submit to the wrong unit or multiple units.
Section 5 - Secure NYS OPWDD Application Authorizer Approval
This section to be completed by a NYS employee ONLY and only if section 2 application chosen states Section 5 is required.
Filling out the IMS-01 form requires careful attention to detail. Each section must be completed accurately to ensure a smooth processing of your request. Follow these steps to fill out the form correctly.
The IMS-01 form is designed for individuals seeking access to the New York State Office for People With Developmental Disabilities (OPWDD) systems. This form allows users to request a User ID and specify the level of access they need, whether it's granting, modifying, or revoking access to specific applications. It ensures that all users understand their responsibilities and the confidentiality of the information they will handle.
The form should be completed by employees of agencies that provide services under the OPWDD. It is important that individuals who have not officially started working at the agency do not request access. All information must be typed in, as handwritten entries are not accepted.
If any section of the form contains handwritten, false, or missing information, it will be rejected. Therefore, it is crucial to double-check all entries for accuracy before submitting the form. If you notice an error after submission, you will need to fill out a new form.
If you no longer require access, it is your agency's responsibility to submit a "CLOSE" request. This request must be made using sections 1, 2, and 4 of the form. Failure to submit this request may lead to potential HIPAA violations, so it is essential to act promptly.
Once you have filled out the form correctly, submit it to the appropriate unit listed at the bottom of the form. Be sure not to submit the form to multiple units or the wrong unit, as this could delay processing. If you have questions regarding the submission process, refer to the contact information provided in the form.
Filling out the Ims 01 form can be a straightforward process, but many individuals make common mistakes that can lead to delays or rejections. One frequent error is the inclusion of handwritten information in sections that explicitly require typed entries. Sections 1 and 2 must be completed without any handwritten notes. If any part of these sections is handwritten, the form will be rejected outright. This requirement emphasizes the importance of using the appropriate software to fill out the form correctly.
Another mistake often made is leaving blank fields in the required sections. Each box in sections 1 and 2 must be filled out completely. If a field does not apply, individuals should enter an "X" or another specified notation as instructed. Failing to provide all necessary information can lead to the form being deemed incomplete, which can significantly delay the processing of access requests.
People sometimes misinterpret the instructions regarding their legal names. The form requires users to provide their full legal names, including the middle initial. If an individual does not have a legal middle name, they must indicate this by typing an "X." Neglecting to clarify this can result in a rejection, as it does not meet the form's requirements.
Another common oversight involves the selection of options from the dropdown menus. Users must select only one option for both the OPWDD User ID Status and Application Access Request. Choosing multiple options or failing to make a selection can lead to confusion and ultimately result in the form being rejected. It is crucial to carefully review these selections to ensure they align with the user's current status and needs.
Finally, individuals often neglect the signature and printed name requirements in Section 4. The form mandates that an Executive Director or authorized designee must sign, print their name, and date the form. Omitting any of these components will render the submission invalid. Therefore, it is essential to double-check that all signatures are complete and correctly formatted before submitting the form.
The IMS-01 form is a critical document used by individuals seeking access to the OPWDD systems. However, there are several other forms and documents that often accompany this request, each serving a specific purpose in the process. Understanding these documents can facilitate a smoother experience when navigating the requirements of the OPWDD. Below is a list of commonly used forms that may be relevant.
By familiarizing oneself with these forms, users can ensure that they are prepared to meet the requirements associated with accessing OPWDD systems. Each document plays a vital role in maintaining the integrity and security of user information and organizational processes.
When filling out the IMS-01 form, adhering to specific guidelines can ensure a smooth process. Below is a list of important do's and don'ts.
Here are five common misconceptions about the Ims 01 form, along with explanations to clarify each point:
This is not true. The Ims 01 form explicitly states that users must type all information. Handwriting can lead to rejection of the form.
In most cases, the Executive Director or an authorized designee must sign the form for it to be valid. Without this signature, the request may not be processed.
This is incorrect. All boxes must be filled out, even if that means entering an “X” to indicate the absence of a middle name. Leaving boxes blank can result in rejection.
This is a misunderstanding. Staff members who have not officially started working at the agency should not request access to the OPWDD systems.
This is misleading. The form includes a statement that users have no legitimate expectation of privacy while using OPWDD systems. Authorized personnel can monitor activities without prior notice.
When filling out and using the IMS-01 form, there are several important points to keep in mind:
Following these guidelines will help ensure a smooth process when using the IMS-01 form. Pay attention to details, and you'll be on the right track.