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Faculty Practice

Commonly Used Forms

HIPAA

Deactivate EHR/RDC User Account Request Form (pdf)

This form is used to request that a users account be deactivated. This form should be submitted prior to the last day of employment for an office of practice employee.

Privacy Information Protected

Centricity New User Account Request Form - Staff (pdf)

This form is used to request the creation of a user account for Centricity EHR/RDC access for a new staff member or provider in a clinic.

Medical History

Centricity New User Account Request Form - Students (pdf)

This form is used to request the creation of a user account for Centricity EHR/RDC access for a new staff member or provider in a clinic.

Patient Packet Spanish

Insurance Request Form (pdf)

If you need to submit a request to Add, Update, or Deactivate an Insurance Provider, please complete the attached form, provide a copy of the insurace card front and back, complete proof of eligibility verification, include the encounter number, and submit it to Janice Jones at  via encrypted email or via Fax.

 

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