Dcf Database Access Request Form Page 4

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20.
Deactivate User is selected when a user is no longer with the agency or a change in job duties no
longer requires access. (The agency must immediately notify the Regional/Managing Entity Data
Liaison or SAMH Security Officer of the user’s separation from the agency and submit a
completed Database Access Request Form with the Deactivate User box checked).
21.
Reactivate User is selected when the user requesting access has previously had an active LDAP
user logon which is currently inactive.
22.
Update user information is selected when the user needs to indicate a change in any of the fields
on the Database Access Request Form. (i.e., name change, change in user type, employer,
etc.).
I.F.
CONFIDENTIALITY AND SECURITY REQUIREMENTS:
23.
Type in dates of Security Awareness Training and HIPAA training
24.
Each person, who requests access to SAMH data or to any departmental data, must sign the
DCF Security Agreement Form (CF 114). By signing this form, the requester affirms that he/she
has read the basic security safeguards as stated in this chapter. By this signature, the user also
affirms that he/she has completed the computer based Security Awareness Training program,
and he/she is aware of both federal and state laws pertaining to data security as listed above.
25.
Once the CF 114 Form is signed and dated, it must be submitted along with a completed
Database Access Request Form and the Completion Certificates for the Security Awareness
Training and the HIPAA training.
26.
Request packets should be submitted to James Lynam at if in
Circuits 3, 4, 5, 7 and 8. Request packets should be submitted to Eugene Carwise at
in Circuits 9 and 18. Subcontracted providers in all other
circuits should submit packets to their ME Data Liaison. Private, licensed substance abuse
providers and private Seclusion/Restraint reporting agencies should submit their packets to Sarah
Griffith at if not in Circuits 3, 4, 5, 7, 8, 9 or 10.

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