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State EPCR ImageTrend Agency Registration

State EPCR ImageTrend Agency Registration

This report should be filled out by agencies looking to utilize ImageTrend for electronic Patient Care Reporting (ePCR).

Today's Date:

Agency Name:

Full Agency Name (no abbreviations)

Agency Physical Address:

Street Address	Street Address
City	City
State	New JerseyState
Zip Code	Zip Code

Agency County:

Agency Phone Number:

XXX-XXX-XXXX

Level of Service:

Level of service that the agency provides. ALS includes any of the following: ground, air, SCTU

ALS

BLS

Both

Other

Type of Service Provided:

911 Emergency Response

Non-Emergency Transport

Both

Agency Affiliation:

Licensed

Volunteer

Both

Other

Municipalities Served:

Agency coverage area

Total Number of Agency Staff:

This section should be filled out by the agency administrator. The agency administrator will be responsible for managing the agency's ImageTrend account.

Primary Contact First Name:

First name of the Agency Administrator. This person should be the primary contact for the agency regarding ePCR.

Primary Contact Last Name:

Last name of the Agency Administrator. This person should be the primary contact for the agency regarding ePCR.

Primary Contact Email:

Primary Contact Phone Number:

I affirm that I am a representative of the listed agency authorized to establish an electronic Patient Care Reporting (ePCR) account through the NJ Department of Health. The agency agrees to abide by all state and federal laws regarding HIPAA as well as policies outlined within the data use agreement.

I have read and understand the above statement and agree to the terms and conditions.