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ERAVE User Application Form

Programs & Services > Certificates & Records > ERAVE > ERAVE User Application Form

Programs & Services

ADH ERAVE User Application Form

Complete the form and sign the user agreement. Once completed, select SUBMIT.

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Applicant's Data

Name(Required)
Business Address(Required)
Do Not enter your home address. Enter your work address.

ERAVE Roles

Funeral Directors, Funeral Director Assistant, Coroner, Deputy Coroner, Physician, Physician Assistant, Medical Examiner, Medical Examiner Assistant, Hospital Death Clerk, Hospital Birth Clerk, Midwife, Hospice RN, and ADH Local Health Unit. List each group/location combination separately. Note: Physicians/Residents, enter the hospital where you primarily work. You will only be given access to one hospital/location.

License/NPI Number

Required for Physicians, Residents, Embalmers, Funeral Directors, Midwives, & Hospice Nurses. For Residents, enter your NPI number. For all others, enter none for license type and license number.
Consent To Electronic Signature(Required)

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