Mississippi Immunization Information eXchange (MIIX) User Agreement

To participate in the Mississippi Immunization Information eXchange (MIIX) Please complete the following information for all staff within your facility who will need access to MS Immunization Information eXchange (MIIX). A user ID and Password will be assigned and emailed to each user. An additional email will be sent with the initial password that will need to be changed once the system is accessed.

If there is an Organizational or Facility name or ownership change, please reach out to our office at 601-576-7751, Option 5.

Organizational Name*

Clinic/Facility or School Name*

Other*

VFC Provider?

Yes

VFC PIN

Has this facility ever had access to MIIX?

Select

COVID Provider?

Yes

COVID PIN

Has this facility ever had access to MIIX ?

Select

Does your facility administer vaccines?*

Public or Privately funded vaccine

Yes

Reason for access request?*

Facility Contact Person*

Facility Address*

Facility City*

Facility State*

Facility Zip*

Facility Phone Number*

Phone

Facility Email Address*

As a condition of participation in MIIX*

As a condition of participating in MIIX the above Facility enters into this agreement with the Mississippi State Department of Health, and agrees to the following: ◆ To use MIIX only for the immunization needs of patients. The Facility and its personnel will access the immunization information system only when needed to assure adequate immunization of a patient, to avoid unnecessary immunizations, to confirm compliance with mandatory immunization requirements, to control disease outbreaks, and to offer recommended vaccines based on ACIP or CDC recommendations. ◆ All Facility personnel that will use MIIX must be assigned User IDs and Passwords by the MIIX Team, and must acknowledge this MIIX “User Agreement.” When an authorized user leaves this Facility, the Facility Manager, Administrator or authorized designee must complete the Remove User form within three (3) days of that employee’s last day of employment. ◆ If the Facility and/or its personnel violate this agreement or use the system in an unauthorized manner, the Mississippi State Department of Health reserves the right to terminate access to the system. ◆ The Facility agrees that it will safeguard its User IDs and Passwords against use other than that allowed by this agreement. ◆ The Facility understands that unauthorized disclosure of confidential information may result in legal penalties. The Facility is responsible for the actions of its staff regarding the confidentiality of information contained in the immunization information system. Each user will be sent an email that outlines these conditions of participation when they are issued a User ID and Password. ◆ The Facility agrees to furnish MIIX specified demographic and immunization information about patients receiving immunizations. The Facility shall submit information to MIIX promptly, striving for submission within twenty-four hours after the vaccine was administered. Selecting "I Agree" below signifies agreement to be a participating Facility and a MIIX authorized user.

I Agree

Acknowledge the following*

I Acknowledge the following below for all users my organization is requesting access: ◆ He/she agrees to abide by this MS Immunization Information eXchange “User Agreement” by only sharing the information provided with those parties requesting immunization records with legal rights to said records. ◆ He/she agrees to abide by the MSDH Immunization Manual and any applicable federal and/or state laws, policies and regulations (e.g., HIPAA) as it relates to security, privacy and management of immunization data and records. ◆ Information contained can only be used for those purposes outlined in this “User Agreement.” ◆ Each user is responsible for the safeguard of his/her User ID and Password. ◆ User IDs and/or Passwords must not be given to any unauthorized user. ◆ User IDs and Passwords should not be posted in a public area.

I Acknowledge

Please add user information below.

First Name*

Last Name*

Position/Title*

Email*

Access Level*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a second user?

Yes

First Name 2*

Last Name 2*

Position/Title 2*

Email 2*

Access Level 2*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a third user?

Yes

First Name 3*

Last Name 3*

Position/Title 3*

Email 3*

Access Level 3*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a fourth user?

Yes

First Name 4*

Last Name 4*

Position/Title 4*

Email 4*

Access Level 4*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine, you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a fifth user?

Yes

First Name 5*

Last Name 5*

Position/Title 5*

Email 5*

Access Level 5*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine, you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a sixth user?

Yes

First Name 6*

Last Name 6*

Position/Title 6*

Email 6*

Access Level 6*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine, you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a seventh user?

Yes

First Name 7*

Last Name 7*

Position/Title 7*

Email 7*

Access Level 7*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine, you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add an eighth user?

Yes

First Name 8*

Last Name 8*

Position/Title 8*

Email 8*

Access Level 8*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine, you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a ninth user?

Yes

First Name 9*

Last Name 9*

Position/Title 9*

Email 9*

Access Level 9*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine, you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Add a tenth user?

Yes

First Name 10*

Last Name 10*

Position/Title 10*

Email 10*

Access Level 10*

Ordering/Inventory - Allows users to add administration data and/or order/reconcile vaccine request (if a MSDH Provider)

Document Vaccine Administration - Allows users to add administration data only.

Read Only - Allows users view MIIX for informational purposes only. If your facility does not administer vaccine, you may only be eligible for Read Only Access.

Reset Password - Request password reset for staff that are registered as users for your Org/Facility.

Ordering/Inventory

Document Vaccine Administration

Read Only

Reset Password

Select "Please send me a copy of my responses" below.

Have each user requested sign a copy and keep on file.

Send me a copy of my responses

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