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State EPCR ImageTrend Agency Registration

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:
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Agency Name:
Full Agency Name (no abbreviations)
Agency Physical Address:
Street Address
City
State
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
d32941412577446faf268deb00414699 ALS 
d32941412577446faf268deb00414699 BLS 
d32941412577446faf268deb00414699 Both 
d32941412577446faf268deb00414699 Other 
Type of Service Provided:
d32941412577446faf268deb00414699 911 Emergency Response 
d32941412577446faf268deb00414699 Non-Emergency Transport 
d32941412577446faf268deb00414699 Both 
Agency Affiliation:
d32941412577446faf268deb00414699 Licensed 
d32941412577446faf268deb00414699 Volunteer 
d32941412577446faf268deb00414699 Both 
d32941412577446faf268deb00414699 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 agencies 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.
da757946e74441a39ec90c065045388b I have read and understand the above statement and agree to the terms and conditions.