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X6TFSMf5YISnf5Nar4nAzUhEVHAcSEtGYunMArAyJ3hVxwn4YQGwsXNjnyDivHnPDthYXWtERHGjpkfiaa5FB2SIKXS8kaT5UkbWAZSFcMxCgdMW6PR

BIDLS Massachusetts Vaccination Program| Color Site User Agreement Application

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To operationalize the efficient and timely distribution and administration of vaccines in Massachusetts, the Massachusetts Department of Public Health (Department or DPH) is working with municipal and regional public health authorities in Massachusetts, as well as with private entities operating vaccination sites at the Department's request (collectively, Commonwealth Sites).

The Department has entered into contract with Color Health for certain Vaccine Clinic Management or VCM Platform Services (the Color Application) to facilitate necessary functions for operating a vaccination site, including but not limited to appointment scheduling, record keeping, and applicable billing. The Department is making the Color Application available to Commonwealth Sites, pursuant to the terms of this Commonwealth Site User Agreement (Agreement) and the terms of any other applicable contracts or agreements with the Commonwealth Site.

The Commonwealth Site (Site) executing this Agreement has met all criteria for hosting, a vaccine clinic or clinics (as applicable). The Site may be able to use Color Application to:

1) Facilitate clinic scheduling

2) Allow vaccine recipients to enter their registration, demographic, and if applicable, insurance information

3) Collect and maintain the information about the vaccine administered

4) Track vaccine inventory

5) Complete the reporting to the Massachusetts Immunization Information System (MIIS) mandated by M.G.L. c. 111 §24M and 105 CMR 220

6) If the below box is checked, to bill vaccine recipients' insurance for the allowable costs of vaccine administration

7) and other uses as may be further made a part of the Color Application.

Date of Entry:

* must provide value

M-D-Y

Note: If the Site is not a public health authority, the Site acknowledges there may be additional written assurance required to access the Color Application.

Details
Organization Name:
MIIS Site Pin:
Provider Type:
Site intends to use DPH's third-party biller, ForHealth, to bill for administration costs?	Please note that selecting 'Yes' simply indicates an interest in using the billing vendor integrated with Color. This does not signify a contract between your organization and the billing vendor or automatic approval of use.

The Designated Responsible Individual (DRI) for the Site is: * The Designated Responsible Individual (DRI) is responsible for ensuring compliance with the terms of the Commonwealth Site User Agreement. This individual serves as the Patient Support Contact in Color.
First Name
Last Name
Phone		Extension (optional)
Email
Title

The Designated Site Color Application Administrator (SA) for the Site is: * DPH will provide the Site Color Application Administrator (SA) with access to the Color Application. The Administrator is then responsible for creating clinic events and onboarding additional users (Site Color Application Users) and assigning the appropriate roles to those Site Color Application Users.
First Name
Last Name
Phone		Extension (optional)
Email
Title

Would you like to appoint a second Site Administrator?

* must provide value

Yes

reset

The Second Designated Site Color Application Administrator (SA) for the Site is:
First Name
Last Name
Phone		Extension (optional)
Email
Title

The Color Application allows anticipated vaccine recipients (Recipients) to book an appointment online. The Site will enter and is responsible for the accuracy of all clinic details including, but not limited to location and time. Recipients and Sites will enter identifiable, confidential information (Recipient Information) into Color Application that the Department, any applicable authorized Commonwealth vendor, and Site will then have access to. Site may only use this information for the purpose of vaccination and as further required by law.
Site acknowledges that in its use of the Color Application, it may receive and/or create health and other information about individuals that is confidential and may also constitute HIPAA Protected Health Information (PHI) as defined by 45 CFR § 160.103. Site will comply with the requirements of HIPAA and all other applicable state or federal laws governing the privacy or security of any Recipient Information, including but not limited to PHI.
Site may use the Color Application solely for the purpose of facilitating vaccination in accordance with applicable guidance, including from the Department. Site may not transfer or make the Color Application available to other third parties for any purpose, including, without limitation, vaccination efforts.
Site is granted a use and access right only and is not transferred any ownership of the Color Application. This Agreement does not transfer title, copyright, intellectual property rights, or distribution rights of the Color Application to Site. Site may not modify, reverse-engineer, or de-compile the Color Application in any manner through current or future available technologies.
Site further agrees, represents, and warrants that:
- Site may not use the Color Application or the Recipient Information for purposes other than allowed by this Agreement and as otherwise required by law;
- the designated Site Color Application Administrator User, and any additional users, have attended the trainings offered, reviewed the written training materials provided, and will comply with these and any future modifications to training materials;
- Site will utilize the Color Application consistently with the principles of role- based access; minimum necessary use of confidential information, including Recipient Information and PHI;
- Site will comply with all applicable law, and,
- Site's Responsible Individual, Color Application Administrator, and any additional Site Color Application Users will comply with all applicable terms of this Agreement
Each Site Color Application User (including, but not limited to, Site's Color Application Administrator) shall:
- Execute and comply with the terms of the Massachusetts Vaccination Program Color Application Individual User Agreement
- Be trained in appropriate access to and use of confidential information
- Be subject to compliance auditing of the user's Color Application access and use
- Report any improper use of the Color Application to the Department
- Not share individual passwords or log on information with any other individual
- Maintain the security of the Color Application and the Recipient Information contained therein
- Only access confidential information, including Recipient Information and PHI, in accordance with the user's appropriate role and only for the purposes described in this Agreement.

If this Agreement is violated by any Site Color Application User, DPH reserves the right to terminate Site's access to the Color Application. By signing this form and/or by accessing the Color Application, Site agrees to accept and abide by the terms of this Agreement.

Please provide your electronic signature (SA):

* must provide value

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DPH INTERNAL
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