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Electronic Signature Statement of Understanding and Transcription Preference

(Clinic Name) is implementing an Electronic Medical Record (EMR) software solution. Physician/clinician electronic signature is a built-in mechanism within the EMR application and is used for multiple functions within the application, including but not limited to: Prescriptions, Result verification, Transcription, Consultation, and Co-signing mid-level Documentation etc.

All persons utilizing electronic signature acknowledge the following:

1. Electronic Signature takes the place of your hand-written signature, by use of a secured password or biometric verification. All legal responsibilities implied with written signatures are binding with Electronic Signatures. 2. Electronic Signature passwords are highly confidential and must never be shared. 100% responsibility of any functions performed under a secured password is that of the assigned user. Any suspicions that a password is no longer secure must be urgently and immediately reported to the system administrator for auditing and a new password will be assigned to user. 3. Assignment of an Electronic Signature Login/Password will only be given after verification of that person’s identity is verified and a sample of the person’s hand-written signature is obtained and retained in a secure location. 4. Assignment of an Electronic Signature Password will only be given after this agreement has been read and signed by Physician/Clinician.

The signature below is my signature sample on file as well as my acknowledgement of the above information.

Signed: ____________________________________________ Date: _______________

Printed Name: ___________________________________________________________