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Application Form

Electronic Medical Record (EMR)

Acknowledgement of electronic signature and password change

  1. I have selected a confidential password known only to myself for use with electronic medical record system (EMR). I am aware that the password must be a minimum of 8 characters long, including at least one capital letter, a lower-case letter, a number and a character. When I enter my password, I electronically sign the subsequent documentation entered and attest that my entries in the electronic medical record are my entries and my entries alone. To assure this, I will be in constant attendance of any device to which I am logged on until such time I logoff said device.

  2. I will not share my password with any other person under any circumstance for any reason as I realize that doing so will violate Federal, State, and Laws and Facility policy pertaining to the protected health information (PHI) contained within the EMR system – electronic protected Health information (EPHI).

  3. Under no circumstances will I enter EPHI under any other logon except my own. If I forget my logon information, I will notify Loyalty Group who will in turn allow me to create a new password confidentially. I am responsible to review my entries in the EMR to ensure accuracy and completeness I am electronically signing the record and attest to the accuracy and authenticity of the information contained therein.

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