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Authorized User Registration/Termination Form

List the requested NY Care Information Gateway Authorized User(s) below. The Authorized User Manager must ensure that all proposed users will complete training and have provided you with the appropriate proof of identity prior to their inclusion on this form. You can add up to twenty Authorized Users. For larger group registration, please click here for the appropriate excel form.

Authorized user manager information:

You must enter in a date.

I certify that:

  1. I am the Authorized User Manager designated by my organization (the Participant) listed on this form
  2. All proposed Authorized Users listed on this form have provided identifying materials and information to me as required by the NY Care Information Gateway's Policy for User Authorization and Authentication
  3. All proposed Authorized Users listed on this form will complete training as required by the NY Care Information Gateway's Training Policy and ​wi​​ll​ complete the Authorized User Training Attestation
  4. I will maintain the supporting documentation required by the NY Care Information Gateway Policies & Procedures and the Policies & Procedures of my organization
  5. I will submit a request to terminate an account for all end users who are terminated or resigned within 24 hours of this status


Authorized user 1:

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Authorized user 2:

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Authorized user 3:

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Authorized user 4:

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Authorized user 5:

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Authorized user 6:

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Authorized user 7:

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Authorized user 8:

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Authorized user 9:

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Authorized user 10:

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Authorized user 11:

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Authorized user 12:

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Authorized user 13:

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Authorized user 14:

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Authorized user 15:

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Authorized user 16:

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Authorized user 17:

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Authorized user 18:

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Authorized user 19:

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Authorized user 20:


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Long Island
551 North Country Road, Suite 206, St. James, NY 11780

NYC
14 Penn Plaza, 225 West 34th Street, 9th Floor, New York, NY 10122

Queens
P.O. Box 800038, Elmhurst, NY 11380

To reach a NYCIG customer service representative, please call 631-250-9191

For issues related to privacy of your information, please contact us: Privacy@NYCIG.org