CENTRICITY EMR
Electronic Medical Record Access Request Form
Instructions: Complete the required application training. Upon completion, complete and sign the form.
All fields are required in order to grant access.
Date:
Date of Training:
1. Reason for Application: ☐New User for Centricity EMR
☐ Edit User for Centricity EMR ☐ Other:
2.
Last Name:
3.
Contact Number:
4.
Employee ID: (9 No.):
5.
Job Title:
6.
NPI#:
First Name:
M.I.:
(to contact you with your user id information)
Credentials (circle): MD DO APN CNM Other (specify):
(required for providers only)
RowanADS ID
7. Licensed Providers: Do you have a valid NJ medical license?
If yes, give complete NJ license #:
__ Resident-Year
_
(network username)
☐ Yes ☐ No
DEA #:
8. Primary Location of Care:
9. Role Requested: (Select All that Apply)
SECURITY ROLE
ACCESS REQUESTED
Front Desk
Document Management
Medical Records
MA
RN
LPN/CMA
Business Admins /Office Managers
Providers
Resident/Fellow
Students – Edit (must pass the online training)
View Only
Health Educator
Coding Unit
Patient Portal/Clinical Messenger
Reports
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 hard copies of the following for an ePrescribing account: DEA Card, NPI, CDC and Medical License
To Receive your Centricity ID: Request and complete Centricity Training, then Scan the completed form to SOM IRT Clinical Systems
Support Team at somITtraining@rowan.edu, Attn: Security Officer or bring to training class.
FOR SOM IST USE ONLY:
Date received @ SOM IRT: _______; Date ID Created for Centricity EMR: _________ ID given to User: _________________
V 02.26.2016
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.
V 02.26.2016