SMHCS Password Request Form

Sarasota Memorial Health Care System Password Request Form

SARASOTA MEMORIAL HOSPITAL

SUNRISE ENTERPRISE - COMPUTERIZED MEDICAL RECORD

REQUEST FOR ACCESS TO SUNRISE ENTERPRISE

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

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LAST NAME: *

FIRST NAME: *

OCCUPATION (i.e., RN, Pharmacist, Social Worker) *

POSITION: *

DEPARTMENT NAME: *

TELEPHONE NUMBER: *

DOMAIN LOGIN ID/NAME:

EMPLOYEE ID:

	Please check appropiate box and type in space provided:
SMHCS (Full Time, Per Diem, Etc.):	Please check appropiate box and type in space provided:	Please check appropiate box and type in space provided:
Agency (Agency Name):	Please check appropiate box and type in space provided:	Please check appropiate box and type in space provided:
Traveler (Contract End Date):	Please check appropiate box and type in space provided:	Please check appropiate box and type in space provided:
Student (Term End Date):	Please check appropiate box and type in space provided:	Please check appropiate box and type in space provided:

STAFF AUTHORIZATION: DEPARTMENT HEAD, SUPERVISOR, OR MANAGER SIGNATURE (Initials): *

Business Email: *

Personal Email: (Required for Password Reset) *

Cell Phone Number *

+ DATE *

TO EMPLOYEE:

In accordance with SMH Policy #00.PER.14 Confidential/Privileged Information, I have a current Medical Information Confidentiality Statement on file with Human Resources. In accordance with SMH Policy #00.IS.21, I understand I am not to share my password with anyone, and to do so would result in termination.

I understand my password should be changed periodically; there is to be at least 8 characters; I should not reuse my password, and my password should not be of such nature to identify me (children’s name, pet’s name, etc.).

I UNDERSTAND THERE IS A PERMANENT AUDIT TRAIL WHEN I ACCESS A PATIENT’S RECORD.

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.