ALL IN GOOD HEALTH.
4150 Technology Way, Suite 104 ● Carson City, NV 89706 ● (775) 684-4242 ● vitalrecords@health.nv.gov ● dpbh.nv.gov/vitalrecords
Electronic Birth/Death Registry System (VRS)
User Application Form
Due to the sensitivity of the registry system, a photo ID showing the signature
of the person applying for access will be required.
Please attach a copy of your ID with BOTH pages of your application and submit to the Office of Vital Records.
Email: dpbhovers@health.nv.gov
PLEASE PRINT CLEARLY or TYPE * CANNOT process without REQUIRED Information
*Applicant’s Name & Facility Information
*Applicant’s First Name
*Applicant’s Middle Name
*Applicant’s Last Name
*Primary Facility Name (Not Address)
*Applicant’s Telephone Number
*Mailing City
State
Zip Code
List Additional Facilities Needed (Include Business Name AND Addresses) – If none, write “None”.
*E-mail Address (Required)
Use The Email That Is Checked Most Often
A notification for a record requiring signature or rejection will be sent to your Office Manager/Assistant and
you.
*Work E-Mail (Required)
Personal E-Mail (Not Work E-Mail)
(Required For Medical Certifiers & Hospitals ONLY) Administrative Assistant / Office Manager E-Mail Address
*Role
Funeral Arrangers and Facility Admins do not have the legal authority to sign birth or death certificates.
*Please check only one box:
Physician (MD/DO) Coroner/Medical Examiners Facility Admin(medical)
APRN Funeral Director Facility Admin (funeral)
Midwife Funeral Arranger Hospice Admin
State/County Employees Only: State/County Registrar
Other (Specify Office/Program___________
*VALID Medical (MD/DO/APRN) or Funeral Director License Number:
(NO NPI or Driver’s License Numbers)
FOR OFFICIAL USE ONLY Date Received: Date Verified: ID Verified:
Date Completed: Completed By:
Nevada Department of Health and Human Services
OFFICE OF VITAL RECORDS AND STATISTICS
CONFIDENTIALITY PROTOCOL
I agree to comply with this confidentiality protocol for the purpose of using the Electronic Birth/Death Registry System
(VRS) and related software provided by the Nevada Department of Health and Human Services (NDHHS). I understand
the VRS and related software is to be used only for completing birth/death certificates for NSHD and compatible valid
official business purposes.
I understand that certain conditions are required for using the VRS and related software and I agree to abide by the
following:
1. The use of Multi-Factor Authentication as per State of Nevada security protocol. Secondary authentication should
be performed using a device separate from the device used to log into the system.
2. To notify the State of Nevada within 48 hours after the device is lost or stolen to have it secured.
3. The use of the VRS and related software to file birth/death records is required by Nevada Revised Statutes NRS
440.100.
4. The use of my VRS username and password assigned to me by NDHHS, is exclusive to my use. Any other person’s use
of my VRS username and password is prohibited. Misusing my username/password could result in penalties per NRS
440.720 through NRS 440.740 inclusive and NRS 440.780.
5. To treat and maintain all the VRS information as strictly confidential.
6. To secure the VRS and related software by taking all appropriate measures to protect and physically secur
e
s
oftware against unauthorized access.
7. To notify the NDHHS, Office of Vital Records in a timely manner if I should decide to no longer use the VRS and related
software.
8. To not misrepresent myself or any employee or agent of mine as an officer or employee of the State of Nevada. To
not make any claim, demand, or application to, or any right or privilege applicable to an officer or employee of the
N
DHHS; including, but not limited to: worker’s compensation, health, life or malpractice insurance, retirement
membership or credit. I agree to assume responsibility for such liabilities.
9. To hold h
armless and indemnify the State of Nevada, its officers, agents and employees from and against any and all
ac
tions, suites, damages, liability or other proceedings which may arise as a result of performing services hereunder.
This section does not require me to be responsible for or defend against claims or damages arising solely from the
acts or omissions of the State, its officers, agents or employees.
10. To notify the Office of Vital Statistics of any violations of this protocol within 72 hours.
I further understand that failure to adequately protect the VRS information can subject me to both criminal and civic
sanctions; including, but not limited to: a federal civil action pursuant to the Privacy Act, 5 U.S.C. §552a(g), and a federal
criminal action pursuant to the Privacy Act, 5 U.S.C.§ 552a(i).
Print Name:
Signature: Date:
Application is valid for 5 years from date of signature
S
ubmission of this application is NOT valid without a copy of your government
( SIGNATURE MUST MATCH PHOTO ID PROVIDED