90029-ORCF 232 Healthcare Portal Access

Healthcare Portal Access Form Section 232

U.S. Department of Housing and Urban Development Office of Residential Care Facilities

OMB Approval No. 2502-0605 (exp. 11/30/2022)

Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The information is being collected to obtain the supportive documentation that must be submitted to HUD for approval, and is necessary to ensure that viable projects are developed and maintained. The Department will use this information to determine if properties meet HUD requirements with respect to development, operation and/or asset management, as well as ensuring the continued marketability of the properties. Response to this request for information is required in order to receive the benefits to be derived from the National Housing Act Section 232 Healthcare Facility Insurance Program. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number. While no assurance of confidentiality is pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information Act request.

Warning: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).

SECTION 1a: Access Status
Create New Change Existing Delete
SECTION 1b: Access Type
Lender Account Manager Backup Account Manager
SECTION 2: User Information
Last Name:      	First Name:      
E-mail Address:      	Telephone Number:      
Time Zone:
Office Address:                         Street City State Zip Code
Status: Lender HUD Employee Other (Please explain)
SECTION 3: Servicer’s Name
Name:

SECTION 4: Acceptable Use and Password Policy Acceptance
	Password Policy has been reviewed and accepted				[see – Password Policy in the 232 HUD Healthcare Portal Instructional Manual]
	Acceptable Use Policy has been reviewed and accepted				[see – Acceptable Use Policy in the 232 HUD Healthcare Portal Instructional Manual]
SECTION 5: Authorized Signatures
User Signature:		     				     
		Print	Signature			Date
Authorizer Signature:		     				     
		Print	Signature			Date
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
For official use only:
Requester’s Username:
Access completed by:				Date: _______/______/______
Notes:

Instructions for Completing the HUD Healthcare Access Form:

Section 1a: Access Status

Select the functions (Create, Change, or Delete) which reflect the status of which the

user requests. NOTE: The delete function will eliminate all access to the HHcP.

Section 1b: Access Type

Select the type of access of which the user requests (LAM – Lender Account Manager

– an individual who has access to the entire Lender portfolio and who may grant

others access accordingly, BAM – Backup Account Manager – an individual who has

access to the entire Lender portfolio as a backup to the LAM, and who may grant

others access accordingly.

Section 2: User Information

The following are required fields. PLEASE complete them all.

Last Name	Please PRINT the user’s Last name.
First Name	Please PRINT the user’s First Name.
E-mail Address	Please include your Brown box number.
Telephone Number	Please PRINT your telephone number, including the area code.
Time Zone	Please select your time zone.
Office Address	Please provide your office address, to include the street, city, state and zip code.
Status	Please select your current status, if it’s “Other”, please provide a brief explanation of your status.

Section 3: Lender’s Information

The following are required fields. PLEASE complete them all.

Name	Please PRINT the name of the Servicer you are representing.

Section 4: Policy Acceptance

All approved individuals who use the HHcP are obligated to be familiar with those policies regulating their access and use. This is especially true for those handling sensitive and/or confidential information. Indicate in the provided spaces that you have reviewed and agree to the listed policies located in the HHcP Instructional Manual.

Section 5: Authorized Signatures

All individuals requesting access to this account as a LAM or BAM must print, sign and date the form and obtain the signature of the Authorized Lender Representative, prior to receiving access to the HHcP.

Questions?

If you have questions about filling out this form, direct them to HHcP@hud.gov.

Previous versions obsolete Page 6 of 6 form HUD-90029-ORCF (06/2019)