CENTRICITY EMR for SOM
Electronic Medical Record Access Request Form
Instructions: Complete the required application training, and then complete the form. Please print legibly and complete all fields, bold fields are required and access will not be granted without.
DATE: ______Date of Training: ______
1. Reason for Application: (May choose more than one.)
New User for Centricity EMR Edit User for Centricity EMR Other: ______
2. Last Name: ______First Name: ______M.I.: ______
3. Contact Number: ______(to contact you with your user id information)
4. Employee ID: (User authentication to meet HIPAA regulations): ______***REQUIRED
5. Job Title: ______Credentials (circle): MD DO APN CNM Other (specify): ___ Resident-Year _____
6. Do you have a current Rowan e-mail account? Yes No N/A; if yes, address: ______
7. NPI#: ______(required for providers) RowanADS ID______***REQUIRED
8. Licensed Providers: Do you have a valid NJ medical license? Yes No
If yes, give complete NJ license #: ______DEA #: ______
9. Primary Location of Care: ______***REQUIRED
10. Role Requested:
SECURITY ROLE / ACCESS REQUESTEDBusiness Admins/Office Managers
Providers
· eRX Enrollment Needed?
· MQIC Access Needed?
MA/CMA
RN
LPN
Front Desk
Resident/Fellow *see below for ePrescribe requirements
Students - Edit
Document Management
MQIC
View Only
Guest Account** / Access Level: ______
Term Date: ______
By signing below I acknowledge I attended training with full participation and understanding.
Signature of User: ______Date: ______
*Residents must provide the following documents to for an ePrescribing account: DEA Card, NPI, CDC and Medical License
To Receive your Centricity ID: Request and complete Centricity Training, then submit this form:
· SOM IST at fax number 856-566-2860; email to:
FOR SOM IST USE ONLY:
Date received @ SOM IST: ______; Date ID Created for Centricity EMR: ______ID given to User: ______
Confidentiality Statement
All patient Protected Health Information (PHI – which includes patient medical and financial information), employee records, student records, financial and operating data of Rowan University, and any other information of a private or sensitive nature are considered confidential. Confidential Information should not be read or discussed by any employee unless pertaining to his or her specific job requirements.
Examples of inappropriate disclosures include:
· Employees discussing or revealing PHI or other Confidential Information to friends or family members
· Employees discussing or revealing PHI or other Confidential Information to other employees without a legitimate need to know.
· The disclosure of a patient’s presence in the office, hospital, or other medical facility, which may reveal the nature of the illness, without the patient’s consent, to an unauthorized party without a legitimate need to know.
The unauthorized disclosure of PHI or other Confidential Information by employees can subject each individual and Rowan University to civil and criminal liability. Disclosure of PHI or other Confidential Information to unauthorized persons, or unauthorized access to, or misuse, theft, destruction, alteration, or sabotage of such information, are grounds for immediate disciplinary action up to and including termination.
Employee Confidentiality Agreement
I hereby acknowledge, by my signature below, that I understand that PHI and Confidential Information and data to which I have knowledge and access in the course of my employment with Rowan University is to be kept confidential, and this confidentiality is a condition of my employment. This information shall not be disclosed to anyone under any circumstances, except to the extent necessary to fulfill my job requirements. I understand that my duty to maintain confidentiality continues even after I am no longer employed. Further, upon termination with Rowan University I shall return to the University all Confidential Information.
I am familiar that Rowan University has guidelines in place pertaining to the use and disclosure of patient PHI and other Confidential Information. Approval should first be obtained before any disclosure of PHI or other Confidential Information not addressed in the guidelines and policies and procedures of Rowan University is made. I also understand that the unauthorized disclosure of patient PHI and other Confidential Information of Rowan University is ground for disciplinary action, up to and including immediate termination.
In the event of a breach of this agreement, Rowan University may pursue equitable relief. The laws of the State of New Jersey shall govern this agreement.
I also understand that by using any applications my activity will be monitored and reported. I also acknowledge that I will not access any of my own personal accounts or family member’s accounts.
______
Signature of Employee Date
______
Print Name
______
Supervisor/Sponsor Signature
(Must be Department Chair or Department Administrator)
**For Guest Account – Sponsor must specify and validate that a current contract and BAA is in place or the TPO relationship being represented.
V 11.08.2013