New Jersey Department of
Human Services
Division of Aging Services
Salesforce Government Cloud
PORTAL USER ACCESS REQUEST FORM
SF-2_Portal User Access Request Form MAY 22 rev. Page 1 of 3
*Required
*Date of Request: _______________________
A. REQUEST TYPE AND PROVIDER DETAIL
*Portal Access Request Type (Check One):
□ New □ Reactivation - Deactivated Portal User ID: ______________________________________
*Portal Access Requested (Check One):
□ EARC Portal (Hospital)
□ NF Portal / User Profile Requested (Check One): □ NF □ SCNF □ Billing Agent (BA)
□ NJ Choice Portal / User Profile Requested (Check One): □ ADRC □ PACE
*Provider Details:
*Medicaid Provider Number
(if applicable): ________________________________________________
*Provider Name: _____________________________________________________________________
*Street Address: _____________________________________________________________________
*City, State, ZIP Code: ________________________________________________________________
B. PORTAL USER DETAIL
(To be completed by individual requiring portal access)
*Portal User Name (First Name, Middle Initial, Last Name): ______________________________________
*Credentials / Title: ______________________________________________________________________
*Mother’s Maiden Name (for security purposes): ______________________________________________
*Portal User Telephone: __________________________________________________________________
*Portal User Email: _______________________________________________________________________
*EARC / NJ Choice Certification # (if applicable): ____________________
NOTE: Please continue below to read the Salesforce Portal - User Responsibility Acknowledgement,
followed by signing the required Portal User Attestation.
C. SALESFORCE PORTAL – USER RESPONSIBILITY ACKNOWLEDGEMENT
Government agencies have a particular responsibility to maintain the confidentiality and accuracy of
the data that is stored in its computer and electronic systems. The Division of Aging Services (DoAS)
will enforce a policy of user responsibility for access to and use of its Salesforce Portal applications.
• Portal users shall stay current with portal processes by reviewing the portal updates
forwarded by DoAS or those identified directly within the portal.
New Jersey Department of
Human Services
Division of Aging Services
Salesforce Government Cloud
PORTAL USER ACCESS REQUEST FORM
SF-2_Portal User Access Request Form MAY 22 rev. Page 2 of 3
• Portal users shall use the online portal approved by DoAS, which provides for electronic
submission of the EARC, LTC-2 and other related processes specific to user access.
• Portal users shall ensure any submission via the portal is completed as truthfully and accurately as
possible.
• Portal users shall adhere to the requirements of all applicable State and federal laws, rules,
and regulations pertaining to the confidentiality and disclosure of information and records.
All resident information shall be kept confidential under federal and State law.
• Portal users shall use appropriate safeguards to prevent the disclosure of resident protected
health information and other resident personal information. Portal users shall follow the
comprehensive information privacy and security program of their provider organization.
Portal users also shall protect against reasonably anticipated threats to confidentiality.
Portal users shall ensure that all resident information is kept confidential and all printed
information from the portal is stored in a secure location. All information that is no longer
needed by the provider organization shall be shredded or otherwise destroyed.
• P
ortal users shall notify DoAS immediately in the event of suspected or actual improper
breach of resident protected health information or other personal information. In such
event, portal users shall contact DoAS at 609-588-6675.
In a
ddition to the above, by signing this form, I acknowledge that I understand the following portal user
responsibilities:
• P
ortal user passwords are assigned to each user for that individual's use only.
• Portal user shall keep passwords confidential. Passwords shall not to be shared with
anyone, including supervisors.
• Use of t
he portal shall be limited to portal user’s job-related duties only.
• Portal users shall log-off/sign-off from the password protected portal if they are not
physically present. Personal computer users may activate a confidential password-
protected screensaver.
• Portal users shall be held liable for failure to adequately protect their logins, passwords
and confidential data from inappropriate disclosure/use/theft.
Portal user ac
counts not used for 120 days will be automatically deactivated from the system.
A portal user whose account was deactivated and wishes to regain access shall request a
reactivation by submitting a new Portal User Access Request Form.
***DoAS r
eserves the right to revoke a portal user’s account for breach of this agreement. ***
PORTAL USER ATTESTATION
My signature certifies that I have read the User Responsibility Acknowledgement and understand my role
and responsibilities in maintaining the confidentiality of the information inputted and stored within the
portal.
*Date: ____________________
*Portal User Signature: ______________________________________________
New Jersey Department of
Human Services
Division of Aging Services
Salesforce Government Cloud
PORTAL USER ACCESS REQUEST FORM
SF-2_Portal User Access Request Form MAY 22 rev. Page 3 of 3
D. SUPERVISOR ATTESTATION (To be completed by supervisor of individual requiring portal access)
*Supervisor Name (First Name, Middle Initial, Last Name): _________________________________________
*Credentials / Title: _____________________________________________________________________
*Supervisor Telephone: __________________________________________________________________
*Supervisor Email: _______________________________________________________________________
My signature certifies that I am the supervisor for the above named individual for whom portal access is
being requested.
*Date: ________________________________________________________________________________
*Supervisor Signature: __________________________________________________________________
E. ISR ATTESTATION
I hereby attest that the above named individual for whom portal access is requested, is an active
employee or billing agent (NF only) and functions in a role that requires portal access.
*Date: ________________________________________________________________________________
*ISR Name: ____________________________________________________________________________
*ISR Signature: _________________________________________________________________________
NOTE: Any changes to an ISR designation shall be processed through the completion of a new SF-1,
Information Security Representative Form.
F. EMAIL INSTRUCTIONS
Submit the completed SF-2, Portal User Access Request Form via email attachment to DoAS as applicable.
Handwritten and/or faxed forms will not be accepted.
• EARC Portal – Email: EARCRegistratio[email protected]
• NF Portal – Email: Doas-NFPortal.Registration@dhs.nj.gov
• NJ Choice Portal – Email: DoasTrainingU[email protected]
NOTE: Forms with any required information (*) missing, shall be returned for completion. Please submit
any comments or questions to the appropriate email above.
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