Pre-registration form
Obtaining Your MEDePass SM Digital Certificate
MEDePass SM is your digital passport to the virtual world of electronic
health care. With it, any licensed California physician will be able to authenticate him
or herself to any other participating person, entity (such as a health plan or medical
group), or resource on the Internet. In turn, you may rely on any other physician's
MEDePass SM as proof to you that he/she is who they claim to be. This will allow doctors
to safely exchange encrypted electronic mail and share confidential data via restricted
web sites with ease.
The simplest way to explain the MEDePass SM concept is to consider its
analogy to your U.S. Passport. A passport is issued by a recognized third party (the State
Department) and acts as proof of identity for purposes such as entry into foreign
countries and cashing traveler's checks. In a similar way your CMA issued MEDePass SM will
uniquely identify you as you travel through the virtual world of participating health care
persons and organizations, allowing access to restricted web sites and exchange of
sensitive data with confidence.
Note: Filling out this form does not obligate you to accept a MEDePass
SM now or in the future. Current plans are to issue the first 5,000 free of charge to
California physicians. After this initial offer is satisfied, additional certificates will
be issued for a reasonable fee. You do not need to be a CMA member to be eligible for a
MEDePass SM. You do need at minimum a current, valid, unrestricted California Physician
and Surgeon's license from either the Medical Board of California or the Osteopathic
Medical Board of California.
The MEDePass SM certificates will be issued to several hundred physicians by mid-December
for the purpose of usability testing. Wide scale deployment throughout California won't
begin until mid to late January 2000. Please indicate below if you would like to be
included in the usability-testing phase. Doing so would require that you agree to provide
some feedback to the development team regarding the use of your MEDePass SM certificate.
Confidentiality notice:
Information you provide herein will be used only to record your interest in obtaining
a MEDePass SM digital certificate and inform you of program status. Your data will not be
used for any other purpose whatsoever.
California Medical Association
MEDePass SM Pre-registration Form
(Completing this form is an indication of interest. It does not obligate you to accept or
buy a MEDePass SM certificate now or at the time the certificates become available)
Email address__________________________________________
(REQUIRED!)
Name________________________________________________________________________
Last
First
MI
Deg.
Bus. Address (No P.O.
boxes)________________________________________________________________________
Street/Suite
City
_____________________________________________________________________________
State
Zip
Phone
License info.__________________________________________________________________________
California license #
Exp. Date
Signature
Practice or group
name:________________________________________________________________________
Do you want to be a usability tester? Yes No
Which email program do you use: ______________________________ Which
browser do you use:____________________________________
Name of person submitting this form if other than the physician above:
__________________________________________________
Signature of submitter if other than
physician:____________________________________________________________________
Date:______________________________________
Please feel free to contact us:
John R. Hanson - Project Director TEL
1-415-882-5117 or E-mail jrhanson@calmed.org
Dr. Terry Fotré - President / CEO TEL
1-415-882-5152 or E-mail tfotre@calmed.org