Executive Office of Health and Human Services 
		Virtual Gateway
Designation of Access
Administrator 

As specified in the EOHHS Virtual Gateway Services Agreement entered into by and between the Commonwealth of Massachusetts, Executive Office of Health and Human Services (“EOHHS”) and the undersigned organizational user (the “User”), the User hereby designates the individual identified below to act as the User’s Access Administrator.   

The Access Administrator must be a member of the User’s staff in the direct control of the User.  The Access Administrator shall be responsible for communicating to the EOHHS Virtual Gateway Administrator the identity of the individual end users (including employees, contractors, agents and Business Associates) authorized to access the EOHHS Virtual Gateway Services on User’s behalf (each, an “End User” and collectively, the “End Users”).  The Access Administrator shall: (1) provide EOHHS with such information as it may require for each End User; (2) ensure that all information submitted to EOHHS about each End User is current, accurate, and complete; (3) notify EOHHS promptly of any End User whose access rights must be terminated, for example when an End User leaves the employment of the User; and (4) take such actions as EOHHS may direct or require to ensure the security of the Virtual Gateway.  Upon receipt from the Access Administrator of all End User information required by this Agreement and any exhibits or amendments thereto, and any additional information that EOHHS may deem necessary to assign such access rights to End Users, the EOHHS Virtual Gateway Administrator shall assign individual account information and access instructions directly to each End User within 3 business days.  Nothing in this Agreement shall be construed to limit EOHHS’s right to deny access rights to any End User for any reason provided EOHHS serves notice within 3 business days to User of such actions, unless in the view of the Virtual Gateway security requires immediate termination.  If End User access rights are terminated without notice for security reasons, EOHHS will notify the User of such action within 3 business days.  

User must notify EOHHS in writing of any change in its Access Administrator designation within 3 business days of the change.  The User must execute a new “Designation of Access Administrator” form for each new Access Administrator.  EOHHS will provide to the User, within 5 business days of receipt of the new Access Administrator’s designation form, any information needed related to the change in Access Administrators.  EOHHS has the right to terminate the rights of any Access Administrator and to require the User to designate a new Access Administrator.  Notwithstanding authorization by an Access Administrator, EOHHS reserves the right to terminate any authorized user’s access to the Virtual Gateway at any time, with or without cause, without notice and without penalty. 

User/Organization (by an authorized representative)		Access Administrator	

Print User Name (Legal Entity Name) 		Signature 	
			
User FEIN (Tax ID)		Print Name 	
			
Signature 		Print Title 	
			
Print Name 			
			
Print Title 			
 			
Date 			
Virtual Gateway Access Administrator Designation Form

All organizations requesting access to the Virtual Gateway must complete, sign, and return this Access Administrator Designation Form to Virtual Gateway Operations.   
Check one box below to either designate an individual as an Access Administrator or remove them if they no longer function as an Access Administrator.                               				  

Mail to: 	EOHHS Virtual Gateway Operations – Deployment		 Designate
	1 Ashburton Place, Room 1109					  
	Boston, MA 02108							 Remove

Business Service(s): ___________________________________________
			(Ex. EIM/ESM, Common Intake, CBHI, SNP, Etc.)

From: ____________________________________________________________________________ 

Organization: ______________________________________________________________________ 

Telephone: _____________________________	Date: __________________________________ 

Access Administrator Profile Information 		
Organization Name:		
Street Address: 	 	
City, State, Zip Code: 		
Access Administrator’s Name: 		
Access Administrator's Email Address: 		
Work Phone Number:	Fax Number: 		
Back Up Access Administrator Profile Information (optional) 		
Organization Name: 		
Street Address: 		
City, State, Zip Code: 		
Back Up Access Administrator 's Name: 		
Back Up Access Administrator's Email Address: 		
Work Phone Number: 	Fax Number: 		
Organization Approval Signature		
	_____ / _____ / _____ 	
            Authorized Officer Signature	Print Name	Date