new jersey early intervention system provider enrollment
TRANSCRIPT
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New Jersey Early Intervention System Electronic User Enrollment User Guide
PCG Training Team 10/18/2019 and 10/28/2019
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Table of ContentsImportant Message…………...………..…….....…..3
Introduction…………………..…………..……….....4
Helpful Tips……………………..………..…………..5
Before Submitting an Electronic New User
Enrollment Form……………………………….....…6
Submitting an Electronic New User
Enrollment Form…………………..………...…..…..9
After Submitting an Electronic New User
Enrollment Form…………..………….....………....26
Before Submitting an Electronic User
Modification Form………………...……..….....…..28
Modification Enrollment Reasons
Deactivate User from Agency………................30
Change User’s Legal Name………...…….....…43
Change User’s Email…………………...….....…58
Change User’s Phone Number......................…71
Change User’s Specialty…………………..…….84
Change User’s Access Type/Role……….…….100
Add Additional Access Type/Role for User......117
Before Submitting a Procedural Safeguards
Module Completion Certification…………......…134
Submitting a Procedural Safeguards Module
Completion Certification……………..…....……...135
Before Submitting a Professional
License Update………………………………..…….143
Submitting a Professional License Update…….144
Contact Information…………………….….………152
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Important Message
PCG Support is neither responsible for, nor able to, determine if an applicant meets the Personnel Standards for a position prior to a full enrollment packet submission. It is the duty of the agency to complete their own due diligence and determine whether the potential employee meets NJEIS Personnel Standards based on their review of the applicant’s documentation, including transcripts and determination if the degree is a health-related field. PCG Support then verifies the Personnel Standards and conducts specific checks of licenses, etc. to verify correct enrollment.
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Introduction
Starting November 1, 2019 NJEIS Early Intervention Program Administrators will navigate to the appropriate
JotForm link to submit ALL New User Enrollment Forms, User Modification Forms, Procedural Safeguards Module
Completion Certificates, and Updated Professional Licenses electronically.
Please refer to the user guide prior to submitting a New User Enrollment Form, User Modification Form, Procedural
Safeguards Module Completion Certificate and/or updated professional licenses.
LINKS TO EACH SUBMISSION FORM
• New User Enrollment: https://hipaa.jotform.com/90237265242150
• User Modification: https://hipaa.jotform.com/90305715212143
• Procedural Safeguard Certificate Submission: https://hipaa.jotform.com/90504240532142
• Updated Professional License https://hipaa.jotform.com/92760806114152
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Helpful Tips
5
➢ Upload files in a PDF Editor i.e.. Adobe Pro to combine and organize all documents and
pages into one PDF file.
➢ Ensure all pages are rotated upright.
➢ Ensure all pages are legible. Darken and lighten features can be used to make pages
legible.
➢ Organize pages in numerical order.
➢ Highlight all details that support the user meeting all NJ Personnel Standards according to
user specialty/user type.
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Before Submitting an Electronic New User Enrollment Form
1. Verify User meets NJEIS Personnel Standards for requested role/specialty.
The NJEIS Personnel Standards provides a list of all enrollment requirements per role/specialty.
2. Obtain Code of Conduct/E-Signature Verification form signed by User.
http://hus.pcgus.com/NJEISBilling/Public/Documents/16/CodeofConduct_ESignature_Form_2-13-19.pdf
3. Collect User demographic information required for this form.
4. Create single PDF packet containing all required documentation for requested role/specialty (incomplete submissions will not be
processed). Please remember that users already enrolled with other agencies still require a completely new enrollment application, packet,
etc.
5. Save the New Jersey Enrollment PDF Packet as (UserLegalName_AgencyName ). It will be uploaded during this online process.
COMPLETING THE STEPS ABOVE WILL ASSIST AGENCY REPRESENTATIVES TO AVOID REQUIRED FIELD ERROR
MESSAGES.
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Before Submitting an Electronic New User Enrollment Form
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COLLECT REQUIRED USER DEMOGRAPHIC INFORMATION
• Full Legal Name*
• Date of Birth
• Work E-Mail
• Work Phone Number (direct line to user for PCG Help Desk use)
* The name MUST be the same name documented on the user’s professional license
and background check.
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Before Submitting an Electronic New User Enrollment Form
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The New Jersey Enrollment PDF Packet includes…
• ALL documents required according to the NJEIS Personnel Standards.
• A completed Page 4 of the Code of Conduct/E-Signature Verification form
The PDF Packet file must be named and saved as UserLegalName_AgencyName
For example, Paul Practitioner working with 123ABC Agency, PDF Packet file is to be
named, saved, and uploaded as PaulPractitioner_123ABCAgency
Create New Jersey Enrollment PDF Packet
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Personal Information
Navigate to
https://hipaa.jotform.com/90237265242150
Confirm that all “Before you begin” steps are completed.
New User Enrollment
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Personal Information
Steps
1. Select the Agency Name
New User Enrollment
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Personal Information
Steps
2. Enter new User’s Full Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
New User Enrollment
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Personal Information
New User Enrollment
Steps
3. Enter user’s date of birth in the User’s Date of Birth and User’s Date of Birth Verification fields.
3
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Personal Information
New User Enrollment
Steps
4. Enter User’s Work E-mail
4
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Personal Information
New User Enrollment
Steps
5. Enter User’s Work Phone Number
5
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Personal Information
New User Enrollment
Steps
6. Select User’s Access Type
Note: The User Access Type selected will determine User Specialty/User Role dropdown list.
IMPORTANT: TET accessibility will be determined by NJ DOH.
6
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Personal Information
New User Enrollment
The steps below are dependent on the User Access and User Specialty previously selected.
Steps
7. Enter the user’s License Number
(if applicable)
8. Enter License Effective Date
(if applicable)
9. Enter License Expiration Date
(if applicable)
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8 9
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Personal Information
New User Enrollment
Steps
10. Select the checkbox of each document included in the New Jersey User Enrollment PDF Packet.
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Personal Information
New User Enrollment
Steps
11. Select Browse and attach the New Jersey Enrollment Documentation Packet.
Note: The New Jersey Enrollment PDF Packet file must be named as UserLegalName_AgencyName format.
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Personal Information
New User Enrollment
Steps
12. Select the checkbox of each Assurance statement
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Personal Information
New User Enrollment
Steps
13. Enter Agency Representative Name
• First Name
• Last Name
14. Enter Agency Representative Email
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Personal Information
New User Enrollment
Steps
15. Select Preview Answers
15
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Personal Information
New User Enrollment
Preview Answers
Steps
16. Review the information enter for accuracy.
17. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online enrollment form.
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Personal Information
A submission message will appear
New User Enrollment
Submission Message
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Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming new user enrollment form submission.
New User Enrollment
Submission E-mail
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Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming new user enrollment form submission.
New User Enrollment
Submission E-mail
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After Submitting an Electronic New User Enrollment Form
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REMINDER: PCG Support is neither responsible for, nor able to, determine if an
applicant meets the Personnel Standards for a position prior to a full enrollment packet
submission. It is the duty of the agency to complete their own due diligence and
determine whether the potential employee meets NJ EIS Personnel Standards based on
their review of the applicant’s documentation, including transcripts and determination if
the degree is a health-related field. PCG Support then verifies the Personnel Standards
and conducts specific checks of licenses, etc. to verify correct enrollment.
The following websites are reviewed to ensure that the user is in good standing.
• Federal exclusions database: http://oig.hhs.gov/fraud/exclusions.asp
• NJ Treasurer’s exclusion database: www.state.nj.us/treasury/debarred
• NJ Department of Health licensure
database: http://www.state.nj.us/health/healthfacilities/search.shtml
• NJ Division of Consumer Affairs licensure database:
https://newjersey.mylicense.com/verification (for OT, COTA, PT, PTA, SLP,
Audiologist, Social Worker, Nurse, Psychologist, Physician, etc.) Providers with
teaching certificates will not typically have a license, nor will interpreters, CDA/CDS,
etc.
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After PCG Support verifies that the new user enrollment is correct an e-
mail will be sent to the user providing their EIMS username and
temporary password. A follow-up will be sent requesting that the user
replies to the email with a Security Word.
The Security Word must not contain the user’s name and should be
memorable, as it will be requested prior to receiving assistance from
the Help Desk.
After Submitting an Electronic New User Enrollment Form
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This Photo by Unknown Author is licensed under CC BY-NC-ND
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Before Submitting an Electronic User Modification Form
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IMPORTANT: A user modification form submission due to a name
change is to be completed AFTER the user’s background check and
license (if applicable) has been updated with the modified name.
Users are responsible for notifying all agencies of requested
modifications.
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Before Submitting an Electronic User Modification Form
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• The User Modification PDF Packet must be created for the following modification
types…• Change User’s Legal Name
• Change User’s Specialty
• Change User’s Access Type/Role
• Add Additional Access Type/Role for User
• ALL documents required according to the NJEIS Personnel Standards supporting the
modification request.
The PDF Packet file must be named and saved as UserLegalName_MOD_Month Date Year
For example, Paula Practitioner completed all requirements and has a name change to Paula Peterson,
the PDF Packet file is to be named, saved, and uploaded as PaulaPeterson_MOD_100219
Create User Modification PDF Packet
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Personal Information
Steps
1. Select Deactivate User from Agency
User Modification
Modification ReasonDeactivate User from Agency
1
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Personal Information
Steps
2. Select the Agency Name
User Modification
Modification ReasonDeactivate User from Agency
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Personal Information
Steps
3. Enter User’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
User Modification
Modification ReasonDeactivate User from Agency
3
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Personal Information
Steps
4. Enter user’s Date of Birth
User Modification
Modification ReasonDeactivate User from Agency
4
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Personal Information
Steps
5. Enter user’s CURRENT Work E-mail
User Modification
Modification ReasonDeactivate User from Agency
5
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Personal Information
Steps
6. Enter user’s CURRENT Work Phone Number
User Modification
Modification ReasonDeactivate User from Agency
6
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Personal Information
Steps
7. Select the checkbox of each Assurance statement.
User Modification
Modification ReasonDeactivate User from Agency
7
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Personal Information
Steps
8. Enter Agency Representative Name
• First Name
• Last Name
9. Enter Agency Representative Email
User Modification
Modification ReasonDeactivate User from Agency
8
9
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Personal Information
Steps
10. Select Preview Answers
User Modification
Modification ReasonDeactivate User from Agency
10
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Personal Information
Steps
11. Review the information enter for accuracy.
12. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online user modification form.
User Modification
Modification ReasonDeactivate User from Agency
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Personal Information
A submission message will appear
User Modification
Modification ReasonDeactivate User from Agency
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Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the deactivate user from agency form submission.
User Modification
Modification ReasonDeactivate User from Agency
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Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming the deactivate user from agency form submission.
User Modification
Modification ReasonDeactivate User from Agency
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Personal Information
Steps
1. Select Change User’s Legal Name (First, Middle/Maiden, Last)
User Modification
Modification ReasonChange User’s Legal Name
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Personal Information
Steps
2. Select Agency
User Modification
Modification ReasonChange User’s Legal Name
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Personal Information
Steps
3. Enter user’s Legal Name • First
• Middle
• Last
• Maiden/Other/AKA*
4. Enter user’s PREVIOUS Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
User Modification
Modification ReasonChange User’s Legal Name
3
4
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Personal Information
Steps
5. Enter user’s Date of Birth
User Modification
Modification ReasonChange User’s Legal Name
5
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Personal Information
Steps
6. Enter user’s CURRENT Work E-mail
User Modification
Modification ReasonChange User’s Legal Name
6
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Personal Information
Steps
7. Enter user’s CURRENT Work Phone Number
User Modification
Modification ReasonChange User’s Legal Name
7
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Personal Information
Steps
8. Select each checkbox of the New Jersey User Modification Documents Included.
User Modification
Modification ReasonChange User’s Legal Name
8
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Personal Information
Steps
9. Select the Browse and attach the New Jersey User Modification Supporting Documentation PDF Packet.
Note: The New Jersey User Modification Supporting PDF Packet file must be named as UserLegalName_MOD_Month Date Year PDF Packet was uploaded.
For example, PaulaPeterson_MOD_100819
User Modification
Modification ReasonChange User’s Legal Name
9
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Personal Information
Steps
10. Select the checkbox of each Assurance statement
User Modification
Modification ReasonChange User’s Legal Name
10
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Personal Information
Steps
11. Enter Agency Representative Name
• First Name
• Last Name
12. Enter Agency Representative Email
User Modification
Modification ReasonChange User’s Legal Name
11
12
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Personal Information
Steps
13. Select Preview Answers
User Modification
Modification ReasonChange User’s Legal Name
13
53
![Page 54: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/54.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
14. Review the information enter for accuracy.
15. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online user modification form.
User Modification
Modification ReasonChange User’s Legal Name
15
54
14
![Page 55: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/55.jpg)
www.publicconsultinggroup.com
Personal Information
A submission message will appear
User Modification
Modification ReasonChange User’s Legal Name
55
![Page 56: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/56.jpg)
www.publicconsultinggroup.com
Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the change user’s legal name form submission.
User Modification
Modification ReasonChange User’s Legal Name
56
![Page 57: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/57.jpg)
www.publicconsultinggroup.com
Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming the change user’s legal name form submission.
User Modification
Modification ReasonChange User’s Legal Name
57
![Page 58: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/58.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
1. Select Change User’s E-Mail Address
User Modification
Modification ReasonChange User’s E-Mail
58
1
![Page 59: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/59.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
2. Select the Agency Name
User Modification
Modification ReasonChange User’s E-Mail
59
2
![Page 60: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/60.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
3. Enter user’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
User Modification
Modification ReasonChange User’s E-Mail
3
60
![Page 61: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/61.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
4. Enter user’s Date of Birth
User Modification
Modification ReasonChange User’s E-Mail
4
61
![Page 62: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/62.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
5. Enter user’s CURRENT work E-mail and user’s UPDATED Work E-mail.
User Modification
Modification ReasonChange User’s E-Mail
5
62
![Page 63: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/63.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
6. Enter user’s CURRENT Work Phone Number
User Modification
Modification ReasonChange User’s E-Mail
6
63
![Page 64: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/64.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
7. Select the checkbox of each Assurance statement.
User Modification
Modification ReasonChange User’s E-Mail
7
64
![Page 65: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/65.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
8. Enter Agency Representative Name
• First Name
• Last Name
9. Enter Agency Representative Email
User Modification
Modification ReasonChange User’s E-Mail
8
9
65
![Page 66: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/66.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
10. Select Preview Answers
User Modification
Modification ReasonChange User’s E-Mail
10
66
![Page 67: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/67.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
11. Review the information enter for accuracy.
12. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online user modification form.
User Modification
Modification ReasonChange User’s E-Mail
12
67
11
![Page 68: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/68.jpg)
www.publicconsultinggroup.com
Personal Information
A submission message will appear
User Modification
Modification ReasonChange User’s E-Mail
68
![Page 69: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/69.jpg)
www.publicconsultinggroup.com
Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the change user’s e-mail form submission.
User Modification
Modification ReasonChange User’s E-Mail
69
69
![Page 70: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/70.jpg)
www.publicconsultinggroup.com
Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming the change user’s e-mail form submission.
User Modification
Modification ReasonChange User’s E-Mail
70
70
![Page 71: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/71.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
1. Select Change User’s Work Phone Number
User Modification
Modification ReasonChange User’s Work Phone Number 1
71
![Page 72: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/72.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
2. Select the Agency Name
User Modification
Modification ReasonChange User’s Work Phone Number
2
72
![Page 73: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/73.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
3. Enter user’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
User Modification
Modification ReasonChange User’s Work Phone Number
3
73
![Page 74: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/74.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
4. Enter user’s Date of Birth
User Modification
Modification ReasonChange User’s Work Phone Number
4
74
![Page 75: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/75.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
5. Enter user’s CURRENT Work E-mail
User Modification
Modification ReasonChange User’s Work Phone Number
5
75
![Page 76: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/76.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
6. Enter user’s CURRENT Phone Number and user’s UPDATED Phone Number.
User Modification
Modification ReasonChange User’s Work Phone Number
6
76
![Page 77: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/77.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
7. Select the checkbox of each Assurance statement.
User Modification
Modification ReasonChange User’s Work Phone Number
7
77
![Page 78: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/78.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
8. Enter Agency Representative Name
a) First Name
b) Last Name
9. Enter Agency Representative Email
User Modification
Modification ReasonChange User’s Work Phone Number
8
9
78
![Page 79: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/79.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
10. Select Preview Answers
User Modification
Modification ReasonChange User’s Work Phone Number
10
79
![Page 80: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/80.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
11. Review the information enter for accuracy.
12. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online user modification form.
User Modification
Modification ReasonChange User’s Work Phone Number
11
12
80
![Page 81: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/81.jpg)
www.publicconsultinggroup.com
Personal Information
A submission message will appear
User Modification
Modification ReasonChange User’s Work Phone Number
81
![Page 82: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/82.jpg)
www.publicconsultinggroup.com
Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s phone number change form submission.
User Modification
Modification ReasonChange User’s Work Phone Number
82
![Page 83: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/83.jpg)
www.publicconsultinggroup.com
Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s phone number change form submission.
User Modification
Modification ReasonChange User’s Work Phone Number
83
![Page 84: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/84.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
1. Select Change User’s Specialty
User Modification
Modification ReasonChange User’s Specialty
84
1
![Page 85: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/85.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
2. Select the Agency Name
User Modification
Modification ReasonChange User’s Specialty 2
85
![Page 86: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/86.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
3. Enter user’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
User Modification
Modification ReasonChange User’s Specialty
3
86
![Page 87: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/87.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
4. Enter user’s Date of Birth
User Modification
Modification ReasonChange User’s Specialty
4
87
![Page 88: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/88.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
5. Enter user’s CURRENT Work E-mail
User Modification
Modification ReasonChange User’s Specialty
5
88
![Page 89: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/89.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
6. Enter user’s CURRENT Work Phone Number
User Modification
Modification ReasonChange User’s Specialty
6
89
![Page 90: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/90.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
7. Select the user’s CURRENT Specialty and Update User’s Specialty to
User Modification
Modification ReasonChange User’s Specialty
7
90
![Page 91: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/91.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
8. Select each checkbox of the New Jersey User Modification Documents Included
User Modification
Modification ReasonChange User’s Specialty
8
91
![Page 92: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/92.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
9. Select Browse and attach the New Jersey User Modification Supporting Documents Packet.
Note: The New Jersey User Modification Supporting PDF Packet file must be named as UserLegalName_MOD_Month Date Year PDF Packet was uploaded.
For example, PaulaPractitioner_MOD_100819
User Modification
Modification ReasonChange User’s Specialty
9
92
![Page 93: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/93.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
10. Select the checkbox of each Assurance statement
User Modification
Modification ReasonChange User’s Specialty
10
93
![Page 94: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/94.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
11. Enter Agency Representative Name
• First Name
• Last Name
12. Enter Agency Representative Email
User Modification
Modification ReasonChange User’s Specialty
Change User’s Specialty
11
12
94
![Page 95: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/95.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
13. Select Preview Answers
User Modification
Modification ReasonChange User’s Specialty
13
95
![Page 96: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/96.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
14. Review the information enter for accuracy.
15. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online user modification form.
User Modification
Modification ReasonChange User’s Specialty
14
96
15
![Page 97: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/97.jpg)
www.publicconsultinggroup.com
Personal Information
A submission message will appear
User Modification
Modification ReasonChange User’s Specialty
97
![Page 98: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/98.jpg)
www.publicconsultinggroup.com
Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s specialty change form submission.
User Modification
Modification ReasonChange User’s Specialty
98
![Page 99: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/99.jpg)
www.publicconsultinggroup.com
Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s specialty change form submission.
User Modification
Modification ReasonChange User’s Specialty
99
![Page 100: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/100.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
1. Select Change User’s Access Type/Role
User Modification
Modification ReasonChange User’s Access Type/Role
10
0
1
![Page 101: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/101.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
2. Select the Agency Name
User Modification
Modification ReasonChange User’s Access Type/Role 2
10
1
![Page 102: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/102.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
3. Enter user’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
User Modification
Modification ReasonChange User’s Access Type/Role
3
10
2
![Page 103: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/103.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
4. Enter user’s Date of Birth
User Modification
Modification ReasonChange User’s Access Type/Role
4
10
3
![Page 104: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/104.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
5. Enter user’s CURRENT Work E-mail
User Modification
Modification ReasonChange User’s Access Type/Role
5
10
4
![Page 105: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/105.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
6. Enter user’s CURRENT Work Phone Number
User Modification
Modification ReasonChange User’s Access Type/Role
6
10
5
![Page 106: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/106.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
7. Select the user’s CURRENT Access Type/Role and update user’s Access Type/Role.
User Modification
Modification ReasonChange User’s Access Type/Role
7
10
6
![Page 107: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/107.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
8. Select User’s Specialty
User Modification
Modification ReasonChange User’s Access Type/Role
8
10
7
![Page 108: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/108.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
10. Select each checkbox of the New Jersey User Modification Documents Included
User Modification
Modification ReasonChange User’s Access Type/Role
10
10
8
![Page 109: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/109.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
11. Select Browse and attach the New Jersey User Modification Supporting Documents Packet.
Note: The New Jersey User Modification Supporting PDF Packet file must be named as UserLegalName_MOD_Month Date Year PDF Packet was uploaded.
For example, PaulaPractitioner_MOD_100819
User Modification
Modification ReasonChange User’s Specialty
11
10
9
![Page 110: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/110.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
12. Select the checkbox of each Assurance statement
User Modification
Modification ReasonChange User’s Access Type/Role
12
11
0
![Page 111: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/111.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
13. Enter Agency Representative Name
• First Name
• Last Name
14. Enter Agency Representative Email
User Modification
Modification ReasonChange User’s Access Type/Role
13
14
11
1
![Page 112: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/112.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
14. Select Preview Answers
User Modification
Modification ReasonChange User’s Access Type/Role
14
11
2
![Page 113: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/113.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
16. Review the information enter for accuracy.
17. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online user modification form.
User Modification
Modification ReasonChange User’s Access Type/Role
11
3
16
17
![Page 114: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/114.jpg)
www.publicconsultinggroup.com
Personal Information
A submission message will appear
User Modification
Modification ReasonChange User’s Access Type/Role
114
![Page 115: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/115.jpg)
www.publicconsultinggroup.com
Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.
User Modification
Modification ReasonChange User’s Access Type/Role
115
![Page 116: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/116.jpg)
www.publicconsultinggroup.com
Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.
User Modification
Modification ReasonChange User’s Access Type/Role
116
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Personal Information
Steps
1. Add Additional Access Type/Role for User
User Modification
Modification ReasonAdd Additional Access Type/Role for User
11
7
1
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Personal Information
Steps
2. Select the Agency Name
User Modification
Modification ReasonAdd Additional Access Type/Role for User 2
11
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Personal Information
Steps
3. Enter user’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
User Modification
Modification ReasonAdd Additional Access Type/Role for User
3
11
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Personal Information
Steps
4. Enter user’s Date of Birth
User Modification
Modification ReasonAdd Additional Access Type/Role for User
4
12
0
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Personal Information
Steps
5. Enter user’s CURRENT Work E-mail
User Modification
Modification ReasonAdd Additional Access Type/Role for User
5
12
1
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Personal Information
Steps
6. Enter user’s CURRENT Work Phone Number
User Modification
Modification ReasonAdd Additional Access Type/Role for User
6
12
2
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Personal Information
Steps
7. Select user’s CURRENT Access Type/Role and select the Additional Access Type/Role for user
User Modification
Modification ReasonAdd Additional Access Type/Role for User
7
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3
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Personal Information
Steps
8. Select User’s Specialty (if applicable)
NOTE: The Select User’s Specialty field can be left blank or “Not Applicable” can be selected.
User Modification
Modification ReasonAdd Additional Access Type/Role for User
8
12
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Personal Information
Steps
9. Select each checkbox of the New Jersey User Modification Documents Included
User Modification
Modification ReasonAdd Additional Access Type/Role for User
9
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Personal Information
Steps
10. Select Browse and attach the New Jersey User Modification Supporting Documents Packet.
Note: The New Jersey User Modification Supporting PDF Packet file must be named as UserLegalName_MOD_Month Date Year PDF Packet was uploaded.
For example, PaulaPractitioner_MOD_100819
User Modification
Modification ReasonAdd Additional Access Type/Role for User
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Personal Information
Steps
11. Select the checkbox of each Assurance statement
User Modification
Modification ReasonAdd Additional Access Type/Role for User
11
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Personal Information
Steps
12. Enter Agency Representative Name
• First Name
• Last Name
13. Enter Agency Representative Email
User Modification
Modification ReasonAdd Additional Access Type/Role for User
12
13
12
8
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Personal Information
Steps
14. Select Preview Answers
User Modification
Modification ReasonAdd Additional Access Type/Role for User
14
12
9
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Personal Information
Steps
15. Review the information enter for accuracy.
16. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit online user modification form.
User Modification
Modification ReasonAdd Additional Access Type/Role for User
15
16
13
0
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Personal Information
A submission message will appear
User Modification
Modification ReasonAdd Additional Access Type/Role for User
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Personal Information
The agency representative will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.
User Modification
Modification ReasonAdd Additional Access Type/Role for User
132
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Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming the user’s access type/role change form submission.
User Modification
Modification ReasonAdd Additional Access Type/Role for User
133
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Before Submitting a Procedural Safeguards Module Completion Certificate
134
IMPORTANT: Save the Procedural Safeguards Module Completion
Certificate as a PDF and name the file using the naming convention
below.
The document must be named and saved as UserLegalName_PSMCC
For example, Paul Practitioner’s Procedural Safeguards Module Completion
Certificate document is named, saved, and uploaded as PaulPractitioner_PSMCC
![Page 135: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/135.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
1. Enter user’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
Procedural Safeguards Module
Completion Certificate
1
13
5
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www.publicconsultinggroup.com
Personal Information
Steps
2. Enter user’s Date of Birth
Procedural Safeguards Module
Completion Certificate
2
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www.publicconsultinggroup.com
Personal Information
Steps
3. Enter user’s Work E-mail.
Procedural Safeguards Module
Completion Certificate
3
137
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Personal Information
Steps
4. Select Browse and attach the Procedural Safeguards Modules Completion Certificate
Note: The user’s Procedural Safeguards Module Completion Certificate must be named as (UserLegalName_PSMCC) format.
For example, PaulaPractitioner_PSMCC
Procedural Safeguards Module
Completion Certificate
4
138
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Personal Information
Steps
5. Select Preview Answers
Procedural Safeguards Module
Completion Certificate
139
5
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Personal Information
Steps
6. Review the information enter for accuracy.
7. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit theProcedural Safeguards Module Completion Certificate.
Procedural Safeguards Module
Completion Certificate
140
7
6
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Personal Information
Procedural Safeguards Module
Completion Certificate
A submission message will appear
141
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Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming their Procedural Safeguards Module Completion Certificate submission.
Procedural Safeguards Module
Completion Certificate
142
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Before Submitting a Professional License Update
143
Save the updated professional license as a PDF and name the file
using the naming convention below.
The document must be named and saved as UserLegalName_PLU_Month Date and Year
For example, Paul Practitioner’s updated professional license PDF document is named,
saved, and uploaded as PaulPractitioner_PLU_101819
Only existing users can submit an updated professional license.
![Page 144: New Jersey Early Intervention System Provider Enrollment](https://reader034.vdocuments.site/reader034/viewer/2022042421/626100f2e31e05417d3f6701/html5/thumbnails/144.jpg)
www.publicconsultinggroup.com
Personal Information
Steps
1. Enter user’s Legal Name
• First
• Middle
• Last
• Maiden/Other/AKA*
* The Maiden/Other/AKA field can be used to indicate a name(s) listed on previously submitted enrollment documents that differs from current name.
Professional License Update
1
14
4
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Personal Information
Steps
2. Enter user’s Date of Birth
Professional License Update
2
145
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Personal Information
Steps
3. Enter user’s Work E-mail.
Professional License Update
3
146
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Personal Information
Steps
4. Select Browse and attach the Updated Professional License
Note: The user’s professional license must be named as (UserLegalName_PLU_Month Date Year) format.
For example, PaulaPractitioner_PLU_101819
Professional License Update
4
147
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Personal Information
Steps
5. Select Preview Answers
Professional License Update
148
5
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Personal Information
Steps
6. Review the information enter for accuracy.
7. Select BACK to edit information.
Select PRINT to print the online enrollment document and file.
Select SUBMIT to submit theupdated professional license.
Professional License Update
149
6
7
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Personal Information
A submission message will appear
Professional License Update
150
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Personal Information
The user will receive an e-mail from NJEIS Support [email protected] confirming their updated professional license submission.
Professional License Update
151
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