Fillable SVMS Terminate Dashboard User Request Practice/Organization/Facility Information User (SacValley MedShare)

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SVMS Terminate Dashboard User Request Practice/Organization/Facility Information User (SacValley MedShare)

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

  • 4 signatures
  • 18 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

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SVMS Terminate Dashboard User Request
An SVMS Terminate Dashboard User Request must be completed for each User whose access to the SVMS
Dashboard user portal is to be terminated. This completed form must be electronically mailed to
support@sacvalleyms.org.
To be Completed by Authorized Organization’s Point of Contact
Practice/Organization/Facility Information
Practice/Organization/Facility: Department:
User Information
Full Name:
Last Name First Name M.I.
User Access to Terminate
• County Access default is Population Health Tile Only (data is de-identified)
County
• County Access to PHI includes COVID Tile
• Provider Practice Dashboards
• Hospital Dashboards
• Payer Dashboards
• Alerts
• Controlled Substances
• Other:
Organizational Contact Signature
By signing below, I certify that the above listed User's access to the SVMS Dashboard System(s) is to be terminated immediately.
Date
Full Name
eMail Address
Point of Contact Signature (required)
To be Completed by SacValley MedShare
User Information to Terminate
Username:
Last Name First Name M.I.
Authorize KONZA to Terminate User?
Yes
No
Date Sent to Konza:
SVMS Agent Signature
SVMS Agent Signature (required)
SVMS Agent Full Name
Date
To be Completed by KONZA
User Information to Terminate
Username:
User Terminated from Dashboards?
Yes
No
Date Sent to SVMS:
Submit To SVMS
Submit to KONZA
click to sign
signature
click to edit
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signature
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KONZA Agent Signature
KONZA Agent Signature (required)
KONZA AgentFull Name
Date
To be Completed by SacValley MedShare
User Access Termination Completed
Full Name:
Last Name
First Name
M.I.
Username:
User Access Termination Completed
• County Access
default is Population Health Tile Only (data is de-identified)
County
• County Access to PHI
includes COVID Tile
• Provider Practice Dashboards
• Hospital Dashboards
• Payer Dashboards
• Alerts
• Controlled Substances
• Other:
Date
Full Name SVMS Agent Signature (required)
SVMS-FORM-138.001 SVMS Terminate Dashboard User Request
SVMS Agent Signature
Submit to SVMS
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signature
click to edit
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signature
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SVMS Terminate Dashboard User Request PracticeOrganizationFacility Information User (SacValley MedShare)

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Completed 5 March 2021

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