Fillable SVMS Terminate Portal User Request User Access to (SacValley MedShare)

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SVMS Terminate Portal User Request User Access to (SacValley MedShare)

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The SVMS Terminate Portal User Request User Access to (SacValley MedShare) form is 1 page long and contains:

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  • 8 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

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SVMS Terminate Portal User Request
SVMS-FORM-131.001 SVMS Terminate Portal User Request
An SVMS Terminate Portal User Request must be completed for each User whose access to the SVMS HIE via
the 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
• User Acceptance Testing (UAT) Access
• Production System (PROD) Access
• Direct Messaging Address
• Other:
Organizational Contact Signature
By signing below, I
certify that the above listed User's access to the SVMS System(s) is to be terminated immediately.
Point o
f Contact Signature (required)
Full Name
eMail Address
Date
To be Completed by SacValley MedShare
User Information
Full Name:
Last Name First Name M.I.
Username:
Direct Message Address:
User Access Termination Completed
• User
Acceptance Testing (UAT) Access
• Production System (PROD) Access
• Direct Messaging Address
• Other:
SVMS Agent Signature
SVMS Agent Signature (required) Full Name
Date
Submit to SVMS
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SVMS Terminate Portal User Request User Access to (SacValley MedShare)

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Completed 5 March 2021

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