2026 3i Intellispace PACS Access Request

Important Note:

Before you start: This form is for 3i Intellispace PACS access only. If you need MedInformatix RIS access instead, email servicedesk@rapc.com
Account Holder

* All Fields Must Be Complete
Account Holder Full Name Account Holder Full Name First Middle Last
Phone Number — best number to reach you Phone Number — best number to reach you - ### - ### ####
Work Email Address (personal addresses such as Gmail or Yahoo can't be accepted)
Last 4 Digits of SSN — used only to confirm your identity
Your Job Title
Who You Work For
Your Work Address Your Work Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Which location(s) do you need to view studies from? List at least one, and be as specific as you can.

(At least one...please be specific)
Authorization of Account Holder

Please provide the contact information for someone other than yourself who can verify your identity and authorize this request. This person should be a physician, manager, supervisor, or other appropriate individual who is familiar with you and your request.

The individual listed below may be contacted to confirm your identity and verify that this request is legitimate and authorized.

By submitting this information, you confirm that the contact information provided is accurate and valid.
Approver's Full Name
Approver's Title
Approver's Phone Number Approver's Phone Number - ### - ### ####

TERMS OF USE AGREEMENT
NOTICE This is a binding agreement. Failure to comply with the terms of this agreement may result in suspension or termination of access privileges, disciplinary action, termination of employment or contractual relationship, and/or other consequences as permitted by applicable law.

Introduction
This agreement explains how you, identified above as "Account Holder", may use 3i's System, the software underlying 3i's System, and patient data and information stored on or accessed through 3i's System.
Integrated Imaging & Informatics ("3i") owns and operates a picture archive and communication system ("3i's System"). 3i's System includes hardware and software owned or licensed by 3i (referred to as the "Hardware" and "Software," respectively). Hardware and Software are subject to license agreements with third parties, copyright law, patent law, and trade secret law.
3i and Account Holder have signed a PACS Storage and Access Agreement (the "PACS Agreement") setting forth the terms and conditions under which 3i has agreed to allow Account Holder and its authorized users to use 3i's System to store and access information. One requirement of the PACS Agreement is that each individual user sign an agreement setting forth the terms of use of 3i's System before becoming authorized to use 3i's System. This agreement fulfills that requirement. Accordingly, you will only be authorized to use 3i's System if you sign this agreement.
The terms of this agreement ("Terms") supplement the PACS Agreement and are to be interpreted consistently with the PACS Agreement. To the extent that the Terms, or any of them, are inconsistent with the PACS Agreement, the PACS Agreement shall control.
AGREEMENT

By signing below, I understand and agree to all of the following:
General Requirements

• I agree to handle all information obtained through 3i's System with the utmost confidentiality and understand that 3i is granting me access to 3i's System solely for use in the course and scope of my services for the Account Holder.
• I agree to use 3i's System only in the course and scope of my authorized job duties and responsibilities for the Account Holder.
• I understand that 3i will assign me a unique sign-on code and password (collectively, "User IDs"), as well as access privileges, for the sole purpose of allowing me to use 3i's System.
• I understand that 3i may revoke my right to use 3i's System if I violate these Terms or the PACS Agreement or if my access is otherwise no longer authorized.
• I understand that any negligent or intentional violation of this agreement or breach of patient confidentiality may result in liability to 3i and/or the Account Holder, possible disciplinary action by the Account Holder, termination of employment or contractual relationship, and immediate termination of my privileges to use 3i's System.
• I understand that information stored on or accessed through 3i's System is subject to applicable state and federal confidentiality and privacy laws, including the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations ("HIPAA").
Password/Sign-On Code Terms of Use

• I agree not to leave my workstation unattended while connected to 3i's System.
• I agree to use only my own User IDs to access 3i's System.
• I agree to keep my User IDs confidential and will not permit anyone else to use them.
• I agree to notify the Account Holder immediately if I believe someone else has used or knows my User IDs.
• I will access only the minimum necessary patient information required to perform my authorized job duties, consistent with applicable law and the PACS Agreement.
• I understand that access to 3i's System is logged, monitored, and subject to audit. I understand that my access activity may be reviewed to verify appropriate system use and compliance with privacy and security requirements.
Data/Patient Information

• I have been trained in, understand, and will comply with HIPAA, the Account Holder's privacy and security policies and procedures, and applicable state confidentiality laws.
• I will not access a person's information unless that individual is a patient of the Account Holder or I have another authorized business purpose permitted under the PACS Agreement.
• I will access only records for which I have a legitimate treatment, payment, healthcare operations, or other authorized business need.
• I will access, use, and disclose only the minimum necessary patient information required to perform my authorized duties, except where the HIPAA minimum necessary standard does not apply.
• I will only store and access information on or through 3i's System as allowed by law and the PACS Agreement.
• If I believe anyone has accessed or used 3i's System improperly, I will notify the Account Holder immediately.
• I will not share information stored on or accessed through 3i's System with any person, office, or business except on a legitimate need-to-know basis and as authorized by applicable law and the PACS Agreement.
• I will not knowingly store information on 3i's System that I know to be inaccurate.
Software and Hardware Terms of Use

• I will not reverse engineer, reverse assemble, reverse compile, or otherwise attempt to discover the source code of any Software or part thereof.
• I will not use the Software or 3i's System for any timesharing or service bureau purposes or for any purposes other than those set forth in the PACS Agreement, nor will I sell, rent, sublicense, or otherwise share my rights to use the Software or 3i's System.
• I will not modify, adapt, translate, or create derivative works of the Software or Software documentation.
• I will not disclose or disseminate the Software to anyone not authorized to receive it.
• I will not violate the terms of any software license agreement or laws applicable to the Software.
• I will not connect or install unauthorized equipment, hardware, or software onto 3i's System or use such equipment, hardware, or software to access 3i's System.
• I will not knowingly introduce any virus, malware, or other malicious code onto 3i's System.
• I will not copy Software or Software documentation without specific authorization.
• I will cease using 3i's System immediately upon termination of employment or when I am otherwise notified that I am no longer authorized to access the System. I will promptly return any Software or Software documentation in my possession or control, as applicable.
USER ACKNOWLEDGMENT

By signing below, I acknowledge that I have read and understand the Terms of Use Agreement and agree to comply with its requirements. I certify that the information provided in this request is accurate and that my requested access is necessary to perform my authorized duties.
Account Holder Signature

Signing confirms you have read and agree to the Terms of Use Agreement above.

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Full Name
Account Holder Full Name Account Holder Full Name First Last
Date of Agreement Date of Agreement / MM / DD YYYY

2026 3i Intellispace PACS Access Request

2026 3i Intellispace PACS Access Request

Important Note:

Account Holder

USER ACKNOWLEDGMENT By signing below, I acknowledge that I have read and understand the Terms of Use Agreement and agree to comply with its requirements. I certify that the information provided in this request is accurate and that my requested access is necessary to perform my authorized duties.

USER ACKNOWLEDGMENT

By signing below, I acknowledge that I have read and understand the Terms of Use Agreement and agree to comply with its requirements. I certify that the information provided in this request is accurate and that my requested access is necessary to perform my authorized duties.