Dcf Database Access Request Form
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4DATABASE ACCESS REQUEST FORM
This form should be typed or printed legibly and printed out for signatures. All information must be completed with the
exception of Fax and DCF Log-on where not applicable.
1.
REQUESTER INFORMATION:
Name: First: _________________ MI: ____ Last: _______________________ User SSN: ________________________
Contractor ID (9 digit FEIN): ______________________ Contractor Name: __________________________________________
Provider ID (9 digit FEIN): ________________________ Provider Name: ___________________________________________
Region: ______________
Circuit: _____ County: _______________________
Phone: _______________________
Fax: __________________ Email: _____________________________________________________
Mailing Address: _______________________________________________________________________________________
DCF Issued Log-on (If already assigned one): ___________________
2.
AUTHORIZATION SIGNATURES:
Supervisor’s Name: _____________________________________________
Supervisor’s Signature: ___________________________________________ Signature Date: ________________
SAMH/ME Data Liaison Name: ___________________________________________________________________
⇒ SAMH Data Liaison or Regional Security Officer Signature: ___________________________ Signature Date: ____________
⇒ SAMH HQ Security Officer Signature: _______________________________ Signature Date: ___________
3.
DATABASE SYSTEM(S) TO BE ACCESSED BY THE REQUESTER:
SAMHIS Database:
Query Facility
TANF
Data Visibility Reports
SANDR
DC Aftercare Referral
IRAS (Incident Reporting)
DCF Employees Only:
Access To Recovery (ATR)
SALIS
4.
LEVEL AND ROLE OF THE REQUESTER:
A. SAMHIS Roles: (Choose one)
Administrator
Staff
State
Region/Circuit
Contractor
Sub-Contractor/Provider
DC Facility
B. IRAS Roles: (Choose one)
Viewer
Initiator
Incident Coordinator
Leadership
DCF Employees Only:
Administrator
5.
ACTION REQUESTED:
Add New User
Deactivate User
Reactivate User
Update User Information
6. CONFIDENTIALITY AND SECURITY REQUIREMENTS/CERTIFICATIONS:
By my signature, I acknowledge that I am responsible for safeguarding the confidentiality and security of all information
contained in any of the above data systems (# 3. above) to which I am granted access as required by the following state and federal
laws:
42 Code of Federal Regulation Part 2 and Part 142;
45 Code of Federal Regulation Parts 160 and 164;
Section 394.4615, Florida Statutes;
Section 397.501(7), Florida Statutes;
Section 916.107(8), Florida Statutes;
Section 282.318, Florida Statutes
I received Security Awareness Training on: ____________ and HIPAA Training on: ____________
Certificates Attached
(MMDDYY)
(MMDDYY)
Requestor’s Signature: ____________________________________________ Signature Date: __________________
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