REQUEST FOR ACCESS TO ELECTRONIC HEALTH RECORD

Access for research and quality review purposes is limited to UH medical staff members and UH employees. Medical Informatics Committee (MIC) approval is necessary in cases where the requestor does not have existing access according to their job/role at the University Hospital. Access to clinical applications (i.e., Sovera, Epic, Logician) may be granted upon special request to the MIC. Upon verification of the IRB and CHART REVIEW REGISTRATION, this request will be forwarded to the Medical Informatics Committee for review and approval. Limited access will be provided by the respective department (Medical Records or HS&T).
NOTE: ACCESS WILL NOT BE GRANTED WITHOUT COMPLETION OF REQUIRED TRAINING

EPIC - Requires IST OnlineTraining. Contact Carol Hansen @ hansenca@uhnj.org

PACS - Requires Online Training via Moodle. Contact Jeanine Struck@ struckja@uhnj.org

SOVERA - Contact Health Information Management (HIM) @ (973) 972-4014
IRB Study #*
IRB Expiration Date:*

MonthDayYear
Principal Investigator*
Degree
Department:*
Requestor Name:*
Degree
Office Address (Bldg.):*
Room #:*
City:*
Phone:*
E-Mail:*
NOTE: @gmail, @yahoo, @hotmail, etc. accounts are not acceptable.
Role at University Hospital*

PhysicianAdjunct StaffRutgers StudentOtherOffice StaffResearch AssistantOther Student
If "Other," please explain:
Employed by:*

UHRutgersUPAOther
System(s) Requested*

EpicSoveraPACSLogicianOther
If "Other," please explain:
Requested Until *

MonthDayYear
Date
Reason for access request:*
REQUIRED DOCUMENTS
University Hospital Research Plan*

Select File

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Research Plan information can be found here:
Office of Clinical Research (OCR)
NJMS Cancer Center - Room B-1244
P: (973) 972-5171
F: (973) 972-8290
IRB Approval Letter and/or Modification Letter*

Select File

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IRB Forms and Modification information can be found here:
Institutional Review Board
65 Bergen Street, SSB 511
P: (973) 972-3608
F: (973) 972-0906
EMail: IrbNWK@ca.rutgers.edu
Confidentiality Information Security Agreement Form & Clinical Systems Access Forms (IST)*

Select File

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DOWNLOAD: Confidentiality Information Security Agreement Form & Clinical Systems Access Form
Chart Review Registration*

Select File

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DOWNLOAD: UH Chart Review Registration Form (for chart review studies) click here
Clinical System-Specific Application Training Certificate(s)*

Select File

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HIPAA Training Certificate*

Select File

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REQUIRED SIGNATURES

A completed application is signed by the requestor, a supervising UH physician, and a UH Chief of Service -- and includes ALL of the following:
Requestor (Print Name)*
UH Physician Supervisor (Print Name)*
UH Chief of Service (Print Name)*
____________________________________________________________________________________

IMPORTANT: Before submitting for Medical Informatics Committee consideration, the approved IRB and UH Research Plan must first be approved by the UH Office of Clinical Research. (SEE ABOVE FOR CONTACT INFORMATION).
SUBMISSION INSTRUCTIONS
1. Print a copy of completed form.
2. Obtain ALL required signatures. Sign above printed name.

3. Upload - Scan and upload all required documents as one (1) complete application.

4. Submit - Use button at bottom to submit.

NOTE: Only signed and completed applications will be forwarded to Medical Informatics Committee for review and approval. Please contact Medical Informatics at uhmedicalinformatics@uhnj.org with any questions.
1) PRINT using button at bottom of page. 2) OBTAIN ALL REQUIRED SIGNATURES. 3) UPLOAD. 4) SUBMIT using button at bottom of page.
This form MUST BE SIGNED AND INCLUDED as face sheet. (SIGNED APPLICATION + DOCUMENTATION = A COMPLETE APPLICATION):
Attestation: I have completed UH approved HIPAA and any Compliance training as required to qualify for EHR access. I have read the UH Confidentiality and Security Policy, and understand that I may have my access to the EHR terminated and may have my employment at University Hospital terminated if I violate this policy. Click here to read: POLICY # 831-200-337
Acknowledgement of UH Policy (831-200-337) regarding Requestor’s Use of UH Medical Record.
Upload complete application here: SIGNED APPLICATION + DOCUMENTATION = A COMPLETE APPLICATION):*

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Date:*

MonthDayYear
Date
____________________________________________________________________________________

Below for Medical Informatics Committee Office Use Only

_____________________________________________________
Iris Hererra, MD
UH Chief Medical Information Officer

Date: ___________________________________________

To follow-up on this application, contact: uhmedicalinformatics@uhnj.org
Should be Empty:

REQUEST FOR ACCESS
ELECTRONIC HEALTH RECORD

IRB Forms and Modification information can be found here:
Institutional Review Board
65 Bergen Street, SSB 511
P: (973) 972-3608
F: (973) 972-0906
EMail: IrbNWK@ca.rutgers.edu

REQUEST FOR ACCESS ELECTRONIC HEALTH RECORD

IRB Forms and Modification information can be found here: Institutional Review Board 65 Bergen Street, SSB 511P: (973) 972-3608 F: (973) 972-0906 EMail: IrbNWK@ca.rutgers.edu

REQUEST FOR ACCESS
ELECTRONIC HEALTH RECORD

IRB Forms and Modification information can be found here:
Institutional Review Board
65 Bergen Street, SSB 511
P: (973) 972-3608
F: (973) 972-0906
EMail: IrbNWK@ca.rutgers.edu