Office of Practice Forms

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.

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.

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.

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 jonesjl01@etsu.edu via encrypted email or via Fax.