EpicCare Link Access Request Form: Community Based Providers & Office Staff

Please complete the form below for EpicCare Link access.

EpicCare Link allows you to enter outpatient referral orders and view your patients chart including results and documentation. Each physician can request access for two office staff members. An access request form is required separately per user.


The Epic Access Legal Site Agreement must be signed by a physician and approved by the sponsor before access is granted. Once you submit the form we will email the physician the legal site agreement for signature, notify your sponsor and after you have completed training your EpicCare Link access will be granted.


Thank you,


Email: Providerservices@nyp.org

Website: https://epictogetherny.org/VoluntaryProviders/Pages/default.aspx

 

User Information

Please answer this section based on the person who is needing Epic access.

 

Please enter the FIRST name of user needing access.

 

Please enter the LAST name of user needing access.

 

Select the main campus you/user send patients to.

 

Select all other campuses that you/user send patients to (in addition to the primary campus).

 

Please select your Primary Specialty. If your specialty is not listed please add specialty information in comments section.

 

Please select any specialties in addition to the Primary Specialty. You may select more than one in this section If your specialty is not listed please add specialty information in comments section.

 

Please enter users mobile phone number.

Phone
 
 

Enter users DOB.

 
mm/dd/yyyy
 
 
 

WCM, NYP, CU if you have one

 
 

Legal Agreement Information for Access

Legal Agreement must be signed by a physician only.

 

Please enter the FIRST and LAST name of the physician who will be signing the Legal Site Agreement for your access.

 

Please enter the email of the physician who will be signing the Legal Site Agreement for your access.

 
 

Please enter the physicians NPI # who will be signing the Legal Site Agreement for your access.

 
 

Practice Information Details

 
 

Enter office address/location

 
Phone
 
Phone
 
 

How did you hear about us?

 

In addition to the groups below, if you have a direct contact at any of our campuses please select Direct Contact Person and provide us with their information.

 
 

Hospital/Departmental Leadership Contact

 
 
Phone
 
 

Access Request Form Completed By