Care Link New Site Request Form

Care Link New Site Request Form
Medical Practice Name:*
Practice Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Practice Phone Number:*

Area CodePhone Number
Practice Specialty:*
List all Physicians and APPs associated with this account (full name and NPI):*
List all Physicians and APPs associated with this account:
Each medical practice must identify a Site Administrator. The Site Administrator accepts the role of managing their site's users in EpicCare Link and are responsible for the following:
- Reviewing all site user access at least every 60 days to ensure timely deactivation of terminated or inappropriate users
- Requesting new access for site users who are employees of the site
- Ensuring accuracy and validity of new access requests for site
- Reporting any staff role changes at the site including changes to the Site Admin as well as other users Communications will be sent via EpicCare Link to the Site Administrator who must validate all users or all users left unvalidated will lose access to information and be deactivated.
Site Administrator Acknowledgement:

By signing this form, I acknowledge the following:

I am responsible for reasonably ensuring that all access I authorize is needed by the individual, is appropriate to the individual’s job, and meets the minimum necessary principle (given technical limitations of the system

I will promptly notify Information Systems at ecladmin@southeasthealth.org of any change in my contact information, my areas of responsibility which may affect this role, or any inability to continue to act as an Authorizer.
Site Administrator Name:*
Email:*
example@example.com
Signature*

Clear
Date:*

MonthDayYear
Date
Upload signed Site Level Agreement:*

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