UAB AMBASSADOR PROGRAM

The Ambassador Program allows practitioners and legally designated staff to have complete access to their

patients' UAB records, including admission and discharge summaries, clinical notes, activities and lab results

through a secure web portal. This innovative tool improves communication between UAB Medicine and

referring practitioners, enhancing continuity of care. There is no charge to participate in this program.

To request access to the program, please complete and fax the attached form to Physician Services at

205.731.6406. A secure token, user ID and password will then be created for you. A physician liaison will visit

your office to provide training on the use of the program.

As a practitioner who will be granted access to the protected health information (PHI) provided within

Ambassador, you acknowledge and agree to the following UAB Health System Security Policies:

 The PHI you access is for the continuation of patient care of your patients only.

 Your logon and token cannot be shared with additional personnel other than the Primary User listed

on your request form.

 You are responsible for all activity and usage associated with your logon. Logon activities are regularly

monitored.

 When viewing PHI via Ambassador, you will not leave the computer terminal unattended and will log

off once you have completed your task.

 This privilege will be terminated immediately in the event you view data or medical information of

individuals who are not your patients.

 UAB cannot guarantee that Ambassador will be accessible during a medical emergency.

 UAB cannot guarantee the accuracy, completeness or timeliness of the information within

Ambassador.

 To be connected with other physicians within the practice, the Consent to Link Provider Practice

section must be completed and on file with UAB Physician Services.

If you have any questions or need additional information regarding Ambassador or UAB Medicine, please feel

free to contact Physician Services at 205.934.6890.

Disclaimer

UAB Medicine seeks to enhance the continuity of care for our patients. Physician Services, through UAB Ambassador, aims to

provide enhanced communication between UAB and referring providers throughout the region. UAB Physician Services will

continue to follow the protocol and procedures outlined above, and will modify as necessary to remain in accordance with

privacy and safety measures. Questions or concerns should be directed to: UAB Physician Services, 500 22

St. S.,

Birmingham, AL 35294, 205.934.6890.

Updated NOV 2023

Request for UAB Ambassador Token Access

Consent to Link Providers

HIPPA allows practitioners within the same office to be linked to one another’s Ambassador Portal. Once linked, each

practitioner will be able to view patients of the others within the practice. UAB Physician Services must have the consent

of each practitioner wishing to participate.

_____ I authorize my patient list to be linked – complete Consent to Link form

_____ I do not wish to link my patient list

I have read and understand the terms and conditions (attached) for use of the UAB Ambassador Program. I agree to

abide by these terms and conditions. (We cannot accept signature stamps)

Handwritten Signature ____________________________________________________Date ____________________

Acknowledgement: I acknowledge that I have received my Ambassador Token, Liaison Training and UAB

Ambassador User Guide.

Received Signature ___________________________________________Delivery Date_________________________

Disclaimer:

UAB Medicine seeks to enhance the continuity of care for our patients. Physician Services, through UAB Ambassador, aims to provide enhanced communication between UAB and referring physicians throughout

the

Region. UAB Physician Services will continue to follow the protocol and procedures outlined above, and will modify if

necessary to remain in accordance with privacy and safety measures .Questions or concerns should

be directed to: UAB Physician Services, 500 22

Street S., Birmingham, AL 35294. 205-934-6890.

Please allow up to 10 business days for this token request form to be processed.

For office use only: RPM ____________________ Messenger ____________________ Updated 2024 _______________

Please circle one: Physician Nurse Practitioner Physician Assistant

Provider can chose ONE of the following: RSA key fob token ___ or Smart Phone app: Android ____or iPhone _____

Smart phone app is PROVIDER USE ONLY since it is issued to the provider’s personal device. Cell # _______________

Please fill out the entire form completely and legibly

First Name ______________________ Middle Name _____________ Last Name_________________________

Provider NPI #______________________Practice Name ___________________________________________

Street Address_______________________________________________________________________________

City ______________________________________________ State _____ Zip Code______________________

Office Phone & Ext ___________________Office Fax ______________________ County__________________

Specialty ___________________________ Provider Email __________________________________________

Primary User ______________________________________________________________________________

For Questions, Please Contact Physician Services

205.934.6890 (Phone)

205.731.6406 (FAX)

AmbassadorRequest@uabmc.edu

Consent to Link Provider Practice

Under HIPPA regulations, in order to connect a practice within Ambassador, UAB Physician Services must have the consent of

each provider wishing to participate. UAB Physician Services will only connect those providers who agree to share their patient

lists. Should a practice’s provider choose not to participate in the practice connection, he or she will not appear in the practice

group, and the patient list can only be accessed by their individual Ambassador token. A provider can be removed from a

practice group at any time, and Physician Services should be notified if a provider leaves or relocates to another practice.

Please fax the completed form to Physician Services at 205.731.6406. For additional information or questions regarding this

feature, please call our office at 205.934.6890. Thank you for choosing UAB Medicine

You must print legibly. We cannot accept signature stamps.

Practice Name _____________________________________________________________________________

Practice Address____________________________________________________________________________

Phone# _________________________________ Practice NPI: _______________________________________