COVERED ENTITY

INFORMATION SYSTEM – REMOTE ACCESS REQUEST

Instructions: Legibly complete all blanks and fields in Items 1-8 and return this Request to
Florida Cancer Specialists & Research Institute, LLC (“FCS”) together with the Authorized User’s
signed Confidentiality and Systems Usage Agreement.

1. Date of Request: 04/25/2022

2. Company/Business Name Requesting Access (“Sponsor”): INTEGRACONNECT

Address: 501, SOUTH FLAGLER DRIVE, SUITE 600 WEST PALM BEACH
City: FLORIDA Zip Code: 33401
Phone: 1(800)-742-3069
3. Name of Person Submitting Request (“Requestor”): Ashwin Sridharan
Title: Director - Operations
Phone: 209-661-2300
E-mail: Ashwin.Sridharan@RCS.IntegraConnect.com
4. Name of Person for whom Access is Requested (“Authorized User”): Mukund Mishra
Title: Senior Executive
Phone: 323-458-1873
E-mail: mukund.mishra@rcs.integraconnect.com
5. Expiration of Access (If left blank, access is limited to 90 days; maximum access is 1 year):
6. Requestor must confirm Sponsor’s approval for User’s access: ☐ Approval Confirmed Initial Here:
7. Access Requested:
INDICATE THE APPLICATION(S) FOR WHICH ACCESS IS REQUESTED

Access Category: Application Name:

Electronic Medical Records ☐ OncoEMR (Read Only)
Radiology ☐ PACS
Other: ☐

8. Access Purpose: State the purpose or need for access and list any written agreement to which access relates.
Working as OV Coordinator

For Internal Use Only:

Internal FCS Requestor Compliance Department
Director Level or Above Approval
Name: ☐ Approved ☐Not Approved
Title: Name:
Phone: Signature:
E-mail: Date:
{00144488.DOC/1}
[Covered Entity Remote Access Agreement - Exhibit B-1/Access Request Form – rev’d Jan 2020]
 EXHIBIT B-2

CONFIDENTIALITY AND SYSTEMS USAGE AGREEMENT (“USER AGREEMENT”)

SEE ATTACHED

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[Covered Entity Remote Access Agreement - Exhibit B-2/ User Agreement – rev’d Jan 2020]
 CONFIDENTIALITY AND SYSTEMS USAGE AGREEMENT

✓ I Mukund Mishra, hereby acknowledge and agree that I am being given access to
information systems maintained by Florida Cancer Specialists & Research Institute, LLC
(“FCS”), which may include electronic medical record (EMR), radiology (PACS), practice
management, billing and/or other FCS systems and databases (collectively “FCS Systems”). I
further acknowledge and agree that such access is strictly limited to the uses permitted under the
Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated
thereunder, as amended from time to time (collectively “HIPAA”), and is being granted by FCS
based on representations, warranties, covenants and/or promises made to FCS, and/or
agreements, arrangements or circumstances reasonably relied upon by FCS in permitting me
such access, including, but not limited to, a “Remote Access Agreement” and/or “Business
Associate Agreement” with FCS, and/or my agreement to the terms and conditions of this
Agreement.
✓ I acknowledge and agree that FCS has legal responsibilities for safeguarding the privacy
of its patients and the privacy and security of all patient healthcare information it generates,
creates, receives or maintains, directly or indirectly. I understand that the term “patient
healthcare information” as used above is intended to have the same meaning as the term
“protected health information” (“PHI”) under HIPAA and, where applicable, shall include
electronic PHI (“ePHI”) as defined in HIPAA.
✓ I acknowledge and agree that FCS must protect and maintain the privacy and security of
all PHI and ePHI in whatever form it is expressed, maintained or documented (collectively
“Confidential Information”) in accordance with HIPAA and all other applicable federal and
state law and regulation (collectively “Applicable Law”).
✓ I acknowledge and agree that my unauthorized or unpermitted access or attempt to access
FCS Systems, or my unauthorized or unpermitted access, use, or disclosure of Confidential
Information, would seriously damage FCS and could cause harm or damage to FCS patients.
Therefore, I agree that my access to and use of FCS Systems, and my access to and use of
Confidential Information, shall be subject to following:
1. I represent and warrant that my access to and use of Confidential Information in FCS
Systems either is permitted on the basis of a HIPAA-compliant patient consent, or otherwise is
consistent with Applicable Law permitting me to receive and use Confidential Information
without the consent of the individual to which such Confidential Information pertains (including
45 CFR § 164.506 of the HIPAA “privacy rule”).
2. I will access and use FCS Systems only (a) under the conditions which pertain to such
access and use by me, (b) in compliance with Applicable Law, (c) in accordance with all
applicable FCS rules, policies and procedures pertaining to FCS Systems (“FCS Rules”), and (d)
in accordance with and to the extent of the authority granted to me under Applicable Law, FCS
Rules and this Agreement. I understand that my access rights are limited to that information for
which I have a legitimate reason and legal right to access.

{00144488.DOC/1} 1
[Covered Entity Remote Access Agreement - Exhibit B-2/ User Agreement – rev’d Jan 2020]
 3. I will not share my FCS Systems user ID or password (“Access Credentials”), or use
tools or techniques to break/exploit FCS security measures, nor will I access or connect to
networks or databases in FCS Systems or devices without specific authority. I will promptly
notify FCS if I suspect that my (or any other individual’s) Access Credentials have been
compromised, disclosed or otherwise violated, and of my (or any other individual’s) access to
Confidential Information which I am not (or to my knowledge, such other individual is not)
permitted or authorized to access.
4. I acknowledge I have no expectation of privacy in my use of FCS Systems and that
FCS may log, access, audit, review and otherwise utilize information stored on or transmitted
through its information systems with respect to my access to and use thereof. I agree to reply
promptly to, and reasonably cooperate with, FCS in connection with any investigation, inquiry
and/or request for information pertaining to FCS’s monitoring and auditing processes or
otherwise relating to its efforts to maintain the security of FCS Systems and the privacy and
security of Confidential Information available therein.
5. I acknowledge that my access and use privileges with respect to FCS Systems may be
denied or terminated at any time, for any reason, including, without limitation, upon FCS
determining, in its sole discretion, that I have violated (a) any term or condition of this
Agreement (or any other agreement relating to my access to FCS Systems), (b) any Applicable
Law, or (c) any FCS Rule, and that such violation may be reported to the U.S. Dept. of Health
and Human Services, Office for Civil Rights or other enforcement authority.
6. I acknowledge and agree that the remedies at law for my breach of any covenant or
representation herein may be inadequate and that FCS shall be entitled to injunctive relief in
connection with its enforcement hereof. I further agree that nothing herein shall limit FCS’s
right to any other remedies, including the recovery of damages for my breach.
7. I agree to indemnify and hold FCS harmless from all claims, actions, costs, expenses,
damages, fines, penalties, and liabilities of any kind whatsoever (including attorneys’ fees, costs
and expenses) suffered or incurred by FCS as a result of or relating to my violation of this
Agreement or breach of HIPAA in connection with my access to and use of FCS Systems. This
provision shall survive the termination of this Agreement and any termination of my access to or
use of FCS Systems.
8. If any portion of this Agreement is held to be invalid, illegal or unenforceable, this
Agreement shall be reformed, construed and enforced as if such portion were not a part hereof.
9. This Agreement shall be governed by the laws of the state of Florida without giving
effect to principles of conflict of laws. In any proceeding to enforce FCS’s rights under this
Agreement, FCS shall be entitled to recover (in addition to any other relief or awarded granted)
its reasonable costs and expenses, including attorneys’ fees.

[Please complete and sign the following page]

{00144488.DOC/1} 2
[Covered Entity Remote Access Agreement - Exhibit B-2/ User Agreement – rev’d Jan 2020]
 SIGNATURE PAGE TO CONFIDENTIALITY AND SYSTEMS USAGE AGREEMENT

THE UNDERSIGNED HAS READ AND HEREBY ACKNOWLEDGES AND AGREES

TO THE FOREGOING TERMS AND CONDITIONS OF THIS AGREEMENT AND TO
ABIDE BY SUCH TERMS AND CONDITIONS.

Print Name: Mukund Mishra Signature: ______________________________

Business/Employer Organization: INTEGRACONNECT

Business Address: 501, SOUTH FLAGLER DRIVE, SUITE 600 WEST PALM BEACH

E-mail: mukund.mishra@rcs.integraconnect.com Business Phone: 1(800)-742-3069

Date: 04/25/2022

============================================================================================
For FCS Internal Use Only:

Received by (Print Name): _______________________________ Dept.: ___________ Date Received: ____________

Underlying agreement to which this Agreement relates (check one):

⃝ Remote Access Agreement

Name of Entity/Business receiving Remote Access: _____________________________________

⃝ Business Associate Agreement

Name of Business Associate: __________________________________________________

⃝ None

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[Covered Entity Remote Access Agreement - Exhibit B-2/ User Agreement – rev’d Jan 2020]