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User Modification Form
Authorized agency representatives may use this form to request a modification to a User's demographic information, specialty, and/or access type/role.
Modification Reason(s)
*
Deactivate User from Agency
Change User's Legal Name (First, Middle, Last, Maiden, Other)
Change User's E-Mail Address
Change User's Work Phone Number
Change User's Specialty
Change User's Access Type/Role
Add Additional Access Type/Role for User
Remove Access Type/Role for User
Agency Name
*
EIP: AHS Hospital Corp
EIP: Archway Programs, Inc. dba Step-By-Step
EIP: Bergen County Special Services School District
EIP: Big Apple Therapy Associates LLC
EIP: Catholic Family & Community Services
EIP: Cerebral Palsy League of Union County dba Kaleidoscope
EIP: Children's Specialized Hospital
EIP: Classic Rehabilitation, LTD
EIP: Community Healthcare Systems, LLC
EIP: Compcare Therapeutics Inc.
EIP: Eden Autism Services, Inc.
EIP: Family Resource Associates, Inc.
EIP: Gloucester County Special Services School District
EIP: Hudson Milestones
EIP: Hunterdon Medical Center
EIP: Innovative Interventions, Inc.
EIP: Innovative Therapeutic Services, LLC
EIP: Inspira Medical Centers, Inc.
EIP: JFK HS Community Hospital Group T/A JRI Physical Medicine
EIP: Kid Clan Services, Inc.
EIP: LADACIN Network
EIP: Lee's Developmental Services LLC
EIP: Montclair State University
EIP: Mountain Lakes Board of Education
EIP: New Jersey Institute for Disabilities
EIP: Pillar Care Continuum, Inc.
EIP: P.G. Chambers School
EIP: Pediatric Therapy Resources, LLC
EIP: Progressive Steps, LLC
EIP: Rowan University
EIP: Rutgers, The State University of New Jersey, RBHS NJ Med
EIP: S & S Therapeutics, Inc.
EIP: Salem County Special Services School District
EIP: School for Children with Hidden Intelligence
EIP: Shirley Eves Developmental & Therapeutic Center, Inc.
EIP: St. Joseph's Hospital & Medical Center
EIP: St. Joseph's School for the Blind
EIP: Summit Speech School
EIP: Sunny Days Early Childhood Developmental Services
EIP: The Arc of Bergen & Passaic Counties, Inc.
EIP: The Arc of Essex County Inc.
EIP: The Arc of Somerset County
EIP: The Arc of Union County, Inc.
EIP: The Arc / Warren County Chapter
EIP: TheraCare
EIP: TheraNorth Services, LLC
EIP: Therapy Associates LLC
EIP: Virtua Health System
EIP: Vista Rehab Services
REIC: Family Link
REIC: Mid-Jersey
REIC: Northeast
REIC: Southern New Jersey
SCU: Bergen County Department of Human Services
SCU: Catholic Family & Community Services
SCU: Central Jersey Family Health Consortium Inc.
SCU: Children's Specialized Hospital (Hudson)
SCU: Children's Specialized Hospital (Middlesex, Somerset, Union)
SCU: DAWN Center for Independent Living, Inc.
SCU: Essex County Department of Health & Rehabilitation
SCU: Hunterdon Medical Center
SCU: Ocean County Department of Health
SCU: Southern NJ Perinatal Cooperative
SCU: The Arc/Warren County Chapter, Inc.
SCU: Visiting Nurse Association of Central Jersey
SPOE: Family Link
SPOE: Mid-Jersey
SPOE: Northeast (Helpful Hands)
SPOE: Southern New Jersey
STATE: New Jersey Department of Health
User's Legal Name is
*
First
Middle
Last
Maiden/Other/AKA
User's PREVIOUS Legal Name was
First
Middle
Last
Maiden/Other/AKA
User's Date of Birth
*
/
Month
/
Day
Year
Date
User's CURRENT Work E-mail
*
User's UPDATED Work E-mail
User's CURRENT Work Phone Number
*
User's UPDATED Work Phone Number
User's CURRENT Access Type / Role is:
EIP with Caseload
Ongoing Service Coordinator
EIP Admin
EIP View with Some Edit Access
REIC Admin
REIC Admin - Edit Access *
REIC Admin - View Access
REIC Data Entry EDIT ALL Access *
SCU Admin
SCU View with Some Edit Access
SPOE Admin
SPOE Service Coordinator
SPOE - View with Some Edit Access *
State Admin - Edit Access *
State Admin - Superuser *
State Admin - View Access *
Update User's Access Type / Role:
EIP with Caseload
Ongoing Service Coordinator
EIP Admin
EIP View with Some Edit Access
REIC Admin
REIC Admin - Edit Access *
REIC Admin - View Access
REIC Data Entry EDIT ALL Access *
SCU Admin
SCU View with Some Edit Access
SPOE Admin
SPOE Service Coordinator
SPOE - View with Some Edit Access *
State Admin - Edit Access *
State Admin - Superuser *
State Admin - View Access *
Add Additional Access Type / Role for User:
Not Applicable
EIP with Caseload
Ongoing Service Coordinator
EIP Admin
SCU Admin
SPOE Service Coordinator
User's CURRENT Speciality:
Not Applicable
Audiologist
Behavioral Specialist
Child Development Associate
Child Development Specialist
Family Therapist
Foreign Language Interpreter/Translator
Interpreter for the Deaf
Nurse (Registered)
Nutritionist
Occupational Therapist
Occupational Therapy Asst. (COTA)
Opthamologist
Optometrist
Orientation/Mobility Specialist
Physical Therapist
Physical Therapy Asst. (PTA)
Physician
Psychologist
Service Coordinator
Service Coordinator Associate
Social Worker
Special Educator
Special Educator - Hearing Impaired
Special Educator - Visually Impaired
Speech-Language Pathologist
Update User's Specialty:
Not Applicable
Audiologist
Behavioral Specialist
Child Development Associate
Child Development Specialist
Family Therapist
Foreign Language Interpreter/Translator
Interpreter for the Deaf
Nurse (Registered)
Nutritionist
Occupational Therapist
Occupational Therapy Asst. (COTA)
Opthamologist
Optometrist
Orientation/Mobility Specialist
Physical Therapist
Physical Therapy Asst. (PTA)
Physician
Psychologist
Service Coordinator
Service Coordinator Associate
Social Worker
Special Educator
Special Educator-Hearing Impaired
Special Educator-Visually Impaired
Speech-Language Pathologist
New Jersey User Modification Documents Included
Background Check (required for name changes)
Transcript(s) or Degree(s) (if applicable)
Professional License (if applicable)
Resume (if applicable)
New Jersey User Modification Supporting Documents Packet Upload
Does this individual require impersonation rights?
No
Yes
Assurances
*
I am authorized by my agency to submit User modification materials.
I understand that, by typing my full name in the box below, I am electronically signing this document.
Agency Representative Name
*
First Name
Last Name
Agency Representative Email
*
example@example.com
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Submit
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