SMHCS HIPAA Role Based Form

Sarasota Memorial Health Care System HIPAA Privacy Role Based

SARASOTA MEMORIAL HOSPITAL

SUNRISE ENTERPRISE/CAREVISION - COMPUTERIZED MEDICAL RECORD

REQUEST FOR ACCESS TO SUNRISE ENTERPRISE/CAREVISION

Please type and electronically sign where indicated then click submit to send the form to Clinical & Business Systems.

Please add the following User/Care Provider to the Sunrise Enterprise, Clinical & Business Systems.

*

Order Entry

View Only

Last Name: *

Middle Initial: *

First Name: *

SECRET KEY WORD

TITLE/LICENSURE/CERTIFICATION *

License Number (if doesn't apply type NA) *

I Represent this Entity: *

PRACTICE NAME: *

TELEPHONE NUMBER: *

List ALL physicians names in this practice *

Practice Manager Name *

plus their Business Email Address:
(no personal email adresses please) *

TO OFFICE STAFF: Security and Patient Confidentiality Standards

Focus	Standard
Passwords	Your password is your electronic signature. It will not be shared with anyone, and you will not use anyone else’s password. Doing so will result in termination of Sunrise Enterprise access for all office staff. If you have reason to believe that someone else has used your password, you will immediately change it. Passwords are eight (8) characters long. They are not to be reused, or of such a nature as to identify you. Your Secret Key Word will be used to identify you should you request your password be reset.
Patient Confidentiality	You will access patient records on a business need basis only. Inappropriate or unauthorized access or disclosure of information will not be tolerated, and may result in termination of your remote access.
Audits	An audit trail is generated every time you access a patient’s record. Routine checks of these audit trails are conducted monthly by the Security Officers.
Leaving your workstation	You will log out of Sunrise Enterprise when leaving your workstation. This prevents unauthorized users from viewing records under your password, and ultimately protects you.

PRACTICE MANAGER APPROVAL: (Note: If practice does not have practice manager, physician must sign). Signature confirms Sunrise Enterprise View education completed, and security expectations reviewed with proposed user. User has confirmed understanding of confidentiality agreement.

PRACTICE MANAGER SIGNATURE (Initials): *

EMPLOYEE SIGNATURE (Initials): *

+ DATE: *

The Uniform Electronic Transactions Act (UETA) - Section 7 (d) states "If a law requires a signature, an electronic signature satisfies the law."

Typing your Initials and/or Signature shall be considered your Electronic Signature and is as binding as a handwritten signature.

TYPE OF ACCESS

TYPE OF ACCESS: Complete the table below: Enter P, S, or I in each of the columns/rows below depending on your role.

P = Primary: - Required (routine) to do your job

S = Secondary: Required to do the job, but mostly by exception

I = Incidental: Not required for the job, but access may occur

(Secured) refers to patients admitted to the Bayside Center for Behavioral Health.

	View	Print	Disclose	Transport	Destroy
Facesheet	View	Print	Disclose	Transport	Destroy
Documents	View	Print	Disclose	Transport	Destroy
Results	View	Print	Disclose	Transport	Destroy
Orders	View	Print	Disclose	Transport	Destroy
Documents (Secured)	View	Print	Disclose	Transport	Destroy
Results (Secured)	View	Print	Disclose	Transport	Destroy

Explanation of Type of Access (above):

View: Read and view the information to make decisions appropriate for your position.

Print: To print and place on office chart.

Disclose: Information to persons or entities outside SMH (Attorneys: non-routine requests)

Transport: Moving information from one place to another (should not view)

Destroy: Recycle, pickup, or final legal disposition of records