To complete the Data Security/Confidentiality Individual Application you are
required to have a State of Ohio user account.
To create your State of Ohio user account click on this link https://ohid.ohio.gov
If you need assistance or have questions on the Data Security/Confidentiality
Individual Application please contact us at 1-800-617-6733 Option 4.

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What's This	Account Type :	---------------- State Employee Independent or Agency Provider IAF Submission Agent Medication Administration Nurse or Secretary School District Employee County Board or COG Employee Advocacy and Protective Services Inc.(APSI) Licensure Designee
What's This	Request Type :	---------------- Renew Account Add System Access Change System Access Terminate User Account

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First Name:	MI:     Last Name:
Phone Number:	ex.(###)###-####
Email Address:
	I certify that the listed email is my personal email address and not a group or shared email.

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