EPiC Account Access Request

You can use this form to request and/or approve practice data access to your EPiC dashboard account for a specified general practice enrolled population.

What is the EPiC dashboard?
- EPiC is a free prescribing data analytics tool that can be used to explore practice prescribing behaviours and how they relate to national problems of prescribing practice.
- EPiC is developed by Matui Limited, under contract to Pharmac.
- Use of EPiC is subject to Matui's Condition of Use and Privacy Policy.
Click here to learn more about EPiC.

What data is shown or collected?
- The Requester (you) is seeking approval to view aggregated dispensed data regarding an enrolled practice population only.
- No prescriber or patient data is provided or collected from the general practice or PHO.
- Data is provided, under licence, by the MOH health collections. There is no charge for this service.
EPiC Account Access Request

User account access request form
I, the undersigned, request EPiC account user access for the sole purposes of undertaking clinical quality or education activities on behalf of the general practice/s named in this form.*

First NameMiddle NameLast Name
Signature*

Clear
Date Signed*

DayMonthYear
Date
Requester and Approver details

Please provide the contact information of the person who is requesting and approving EPiC account access. For this form, the Requester (you) will also be an authorised company representative and may act as the Approver. If you are not an authorised company representative (E.g., Practice Manager, Chief Executive, Director, Company owner), please fill out this form instead - https://form.jotform.com/232048560939866
Job title*
Workplace*
Mobile phone*
Enter a New Zealand mobile phone number
Approver's EPiC account login email *
Please provide your EPiC account login if held, or email to be used with EPiC Practice account.
Professional registration number (if applicable)
Additional information
Practices requested

Please provide the name/s of the requested practice/s
Note: One request, for one or more practices, to be completed per Approver.
I request access for Practice Name : Type a label*
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
I request access for Practice Name : Type a label
Address: Street Address Address Line 2 City State Zip
Length of access requested

Indicate the duration of access
Duration of access
You will be contacted after the period to arrange renewal if required.
Additional details

Please provide the company ownership details of the practice/s requested.
Company name (as stated on the NZ Companies Register)*
We check the companies office to make sure that the correct company is allocated to the EPiC account and the approver is authorized to represent the practice or business (https://companies-register.companiesoffice.govt.nz/).
NZBN Number (if known)
Accept
Should be Empty:

EPiC Account Access Request

Requester and Approver details

Practices requested

Length of access requested

Additional details