ROWAN UNIVERSITY
CLINICAL APPLICATIONS
GE CENTRICITY BUSINESS SYSTEM ACCESS REQUEST
Instructions: Complete the required application training. Upon completion, complete and sign the form. All fields are required in order to grant
access.
Select Activity: ☐ Add ☐ Edit ☐ Deactivate
Date of Request:
Effective Date of Change:
Reason for Change:
Last Name:
First Name:
Contact Number:
RUID (core LogIn):
Job Title:
Employee ID (9 No.):
M.I.:
For FPP Users:
Department:
Location:
FPP Profiles:
☐ FPP View Only
☐ Coder
☐ FPP Front Desk-Reg, Sched Charge Entry
☐ Compliance
☐ FPP Level 4 – Includes Master Scheduling *
☐ Managed Care
☐ FPP Bus Admin
☐ Other
☐ Ingenious Med: Please select one of the following. ☐ Admin. (IRT Only) ☐ Physician ☐ Nurse/NP/PA ☐ Biller
.
☐ Practice Admin
Please indicate if this is a guest account: ☐ Term Date:
* Requires FPP Executive Director Approval
For CBO Users:
CBO Profiles:
☐ Biller I
☐ Biller II
☐ CBO Clerk/View Only
☐ Supervisor
☐ Payment Poster I
☐ Payment Poster II
☐ Pre-Reg Unit
☐ Other
.
Please indicate if this is a guest account: ☐ Term Date:
For ETM Users:
ETM Role:
☐ RCM Biller
☐ Coder
☐ Practice Specialist
☐ Pre-Reg
☐ Payment Poster
☐ Credentialing
Work Flow (Select/Complete All that Apply): ☐ Claim Edits (CBO DIV)*:______________
☐ Rejection (CBO DIV)*:____________ ☐ No Activity (CBO DIV)*:______________
☐ Self-Pay ☐ Credit Balance ☐ Pre Visit ☐ Payer Edits ☐ TES
*If split between Divisions, we will also need the MRN split. Any other additional information that would be needed to divide work can be
identified in the comments.
By signing below I acknowledge I attended training with full participation and understanding.
Employee Signature:
Date:
Administrator Authorization:
Date:
COMMENTS:
Scan the completed form to SOM IRT Clinical Systems Support Team at somITtraining@rowan.edu, Attn: Security Officer or bring to training class.
IRT USE ONLY
Revised: 02.26.2016
COMPLETED: ______________
ROWAN UNIVERSITY
CLINICAL APPLICATIONS
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 by signing is validating that a current contract and BAA is in place.
IRT USE ONLY
Revised: 02.26.2016
COMPLETED: ______________