Fillable SVMS New Portal User Request (SacValley MedShare)

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SVMS New Portal User Request (SacValley MedShare)

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The SVMS New Portal User Request (SacValley MedShare) form is 2 pages long and contains:

  • 3 signatures
  • 18 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

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SVMS New Portal User Request
SVMS-FORM-130.001 SVMS New Portal User Request
An SVMS New Portal User Request must be completed for each User who will be accessing the SVMS HIE via the
user portal. 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 #:
License #:
If applicable If applicable
User Access Requested (must choose at least one)
• User Acceptance Testing (UAT) Full Access *
• User Acceptance Testing (UAT) Regular Access
• Production System (PROD) Full Access *
• Production System (PROD) Regular Access
• Direct Messaging Address
• Direct Messaging Administration
• HIM
• Vault Administration
• Other:
* includes access to Substance Use Disorder and Behavioral Health Data
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 aces, 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.
- Type your full name, email address, and the date prior to signing as once signed, the form fields lock.
Point o
f Contact Signature (required)
Full Nam
e
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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signature
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SVMS New Portal User Request
SVMS-FORM-130.001 SVMS New Portal User Request
To be Completed by SacValley MedShare
User Information
Full Name:
Last Name First Name M.I.
Username:
Temporary Password:
Direct Message Address:
User Access Setup Completed
• User Acceptance Testing (UAT) Full Access *
• User Acceptance Testing (UAT) Regular Access
• Production System (PROD) Full Access *
• Production System (PROD) Regular Access
• Direct Messaging Address
• Direct Messaging Administration
• HIM
• Vault Administration
• Other:
* includes access to Substance Use Disorder and Behavioral Health Data
SVMS Agent Signature
SVMS Agent Signature (required) Full Name
Date
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signature
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SVMS New Portal User Request (SacValley MedShare)

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Completed 5 March 2021

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