University of Maryland Medical System Epic Request Form

Please complete this form in order to obtain access to Epic during your clinical rotation at a University of Maryland Medical System (UMMS) hospital. The information entered here will be stored securely and will not be shared with those who do not need access to it.

Please contact Melissa Lay (MelissaLay@umm.edu) for questions about this Smartsheet.

Name of School

Type the name of your school.

First Name

Please enter your legal first name.

Last Name

Please enter your legal last name.

Student or Instructor

Are you a student or are you an instructor?

Student

Instructor

What type of program are you enrolled in?

Please select from the dropdown menu below.

Are you in an ACE group?

Will you be in an inpatient or outpatient area for your clinical rotation?

Inpatient

Outpatient/Ambulatory

UMMS Hospital

Please choose the hospital where you will be in clinicals for this semester.

Email Address

Please use your school e-mail address.

Mobile Phone Number

Unless absolutely necessary, please only enter your mobile number.

Phone

Month of Birth

Please select your month of birth in MM format from the dropdown below. Example: February = 02, March = 03.

Day of Birth

Please select your day of birth in DD format from the dropdown below. Example: You were born on March 5 = select 05 for your day of birth in DD format.

Last 4 Digits of SSN

Please enter only the last 4 digits of your SSN.

Clinical Rotation Start Date

mm/dd/yyyy

Clinical Rotation End Date

mm/dd/yyyy

Name of Person Completing Form

Please type the full name of the person completing this form.

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University of Maryland Medical System ﻿Epic Request Form

University of Maryland Medical System Epic Request Form