Fillable SVMS New Analytical Dashboards User Request Practice/Organization/Facility Information (SacValley MedShare)

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SVMS New Analytical Dashboards User Request Practice/Organization/Facility Information (SacValley MedShare)

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The SVMS New Analytical Dashboards User Request Practice/Organization/Facility Information (SacValley MedShare) form is 2 pages long and contains:

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  • 22 check-boxes
  • 40 other fields

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File type: PDF

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SVMS New Analytical Dashboards User Request
SVMS-FORM-137.001 SVMS New Analytical Dashboards User Request
An SVMS New Portal User Request must be completed for each User who will be accessing the SVMS Analytical
Dashboards. User will receive their secured access information by phone or encrypted electronic mail. This
completed form must be electronically mailed to support@sacvalleyms.org. Fields outlined in red are required.
To be Completed by Authorized Organization’s Point of Contact
Practice/Organization/Facility Information
Practice/Organization/Facility:
Department:
User Information
Full Name:
Specialty:
Last Name First Name M.I.
eMail Address:
Professional Suffix/Title:
NPI #:
If applicable If applicable
User Access Requested (must choose at least one)
County
• County Access default is Population Healt
h Tile Only (data is de-identified)
• County
Access to PHI includes COVID Tile
• Provider Practice Dashboards Patient list may be provided
• Hospital Dashboards Patient list may be provided
• Payer Dashboards Member list must be provided
• Alerts Member or Patient list must be provided
• Controlled Substances **
• Other:
**DISCLAIMER: When Controlled Substances is chosen, by signing this document, you are authorizing the user listed to have access to the
controlled substance dashboard, which contains information that may be deemed extremely sensitive.
Organizational Contact Signature
By signing below, I certify that User has completed the required HIPAA and Confidentiality training and all information
contained herein is accurate. I affirm that all access, by my organization, to the SVMS system(s) shall be in compliance with
the Participation Agreement between our organization and SVMS, applicable law, SVMS governing policies and that
any inappropriate use or access to the SVMS system(s) may result in the imposition of sanctions by SVMS, against me and/
or my organization that could include loss of use of the SVMS system(s), notice to licensing authorities, and/or civil or
criminal penalties. I have certified the identity of the individual.
Point of Contact Signature (required) Full Name eMail Address Date
To be Completed by User
Security Information (Used to verify identity for password resets, etc.)
Month and Day of Birth:
Month:
Day:
Place of Birth or Mother’s Maiden Name:
User Acknowledgement and Signature
It is your responsibility, as an SVMS User, to ensure your password is kept confidential. Your signature below acknowledges
that you understand and agree to be bound by the following statements: 1) To not share your password with anyone or ask
another user for their password. 2) To not login anyone else to the SVMS system(s) using your password.
I understand that any inappropriate access to the SVMS system(s) may result in the imposition of sanctions against me, my
supervisors and/or my organization that could include loss of use of the SVMS system(s), notice to licensing authorities, and/or
civil or criminal penalties.
User Signature (required) Full Name Date
Submit to User
Submit to SVMS
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SVMS New Analytical Dashboards User Request
SVMS-FORM-137.001 SVMS New Analytical Dashboards User Request
To be Completed by SacValley MedShare
User Information
Full Name:
Last Name First Name M.I.
Member/Patient List Received?
Yes
No
Authorized KONZA to Setup User Dashboards?
Yes
No
Date Sent to Konza:
SVMS Agent Signature
SVMS Agent Signature (required) Full Name Date
To be Completed by KONZA
User Information
Username:
Temp Pwd:
Member/Patient List Loaded?
Yes
No
Date Sent to SVMS:
KONZA Agent Signature
KONZA Agent Signature (required)
Full Name (KONZA Agent)
Date
To be Completed by SacValley MedShare
User Information
Full Name:
Last Name First Name M.I.
Username:
Temporary Password:
User Access Setup Completed
County
• County Access default is Population Health Tile Only (data is de-identified)
• County Access to PHI includes COVID Tile
• Provider Practice Dashboards Patient list may be provided
• Hospital Dashboards Patient list may be provided
• Payer Dashboards Member list must be provided
• Alerts Member or Patient list must be provided
• Controlled Substances **
• Other:
SVMS Agent Signature
SVMS Agent Signature (required) Full Name Date
Submit To KONZA
Submit to SVMS
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signature
click to edit
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signature
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click to sign
signature
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SVMS New Analytical Dashboards User Request PracticeOrganizationFacility Information (SacValley MedShare)

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Completed 5 March 2021

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