Policy Manual sample

MDT Home Health Care Agency, Inc. EXHIBIT “A” ELECTRONIC HEALTH RECORD (EHR) ACCESS AUTHORIZATION Staff Name: __________________________________ Title: __________________ Date: _______________ Supervisor: ________________________________________ Title: __________________ Access request to: 9 Full EHR access 9 Limited EHR access, explain: _________________________________ User: _______________________________________ Password assigned: __________________________ Security word for retrieve password: _____________ 9 Signed User Confidentiality Agreement (Exhibit B) 9 Permit granted 9 Permit not granted, explain: _______________________________________________________________________________________ ________________________________________________________________________________________ Staff signature: __________________________________ Date: ___________________ Approval by: Name/Title: _______________________________________________________________________ Signature: _______________________________________ Date: ____________________ Home Health Agency Policies A-175