NJHIN Portal Access Request Form

Submit Below

Please note that by requesting access to the secure portal, you will be able to view information that is considered Electronic Protected Health Information (ePHI) under the federal law known as HIPAA.

By submitting this document, the authorized user agrees to the following terms and conditions:

Agrees to maintain the confidentiality of the account information, including password.
Understands that the information the authorized user will receive by use of the secure portal is confidential and shall not be disclosed to anyone.
Understands and agrees that failure to maintain the confidentiality of user information made available through the secure portal may cause access to be revoked at any time.

Name*
First Last
Title*
Facility Name*
Facility Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
NPI # (If you do not have an NPI, please enter N/A)*
Phone*
Email*
Last 4 Digits of SSN
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Name
This field is for validation purposes and should be left unchanged.