New Facility - EpicCare Form

New Facility Form
Legal Name of Facility
Facility NPI #
Facility Notice of Privacy Practices (Attach PDF)

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Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Note: All site administrators must have an active EpicCare Link account. Your login ID and temporary password will be emailed to you within five business days after your facility is approved.
Site Administrator: Legal Name

Legal First NameLegal Last Name
Site Administrator: Role
Site Administrator: Email Address
example@example.com
Site Administrator: Contact Number

Area CodePhone Number
Additional Site Administrator #1: Legal Name

Legal First NameLegal Last Name
Additional Site Administrator #1: Email Address
example@example.com
Additional Site Administrator #1: Contact Number

Area CodePhone Number
Additional Site Administrator #2: Legal Name

Legal First NameLegal Last Name
Additional Site Administrator #2: Email Address
example@example.com
Additional Site Administrator #2: Contact Number

Area CodePhone Number
Should be Empty:

New Facility Form