Texas Children's EpicCare Link Registration Form

M-D-Y

Request a new EpicCare Link site (use if your clinic does not already have EpicCare Link access)

Modify an existing EpicCare Link site (use if your clinic already has EpicCare Link access)

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Add a Provider (required for new sites)

Add Clinic Staff (Non-Provider)

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Note: So that we can build your clinic/office group properly, please list all Providers in your practice. The maximum capacity of this form is 5 providers. If you need to submit more providers please complete another form.

Approve

Deny

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M-D-Y

Male

Female

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Not a member of the Medical Staff

Active Member

Courtesy Member

Consulting Member

APP Member

AHP Member

Adjunct Member

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Note: Provider will be linked with your group but will retain Epic Hyperspace access

Yes

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Yes

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Note: Site Administrators must have EpicCare Link access. A site administrator is the person responsible for maintaining a site's records. These responsibilities include verifying that user accounts are current, deactivation the accounts of users who are no longer active at the site, and submitting requests to activate new users accounts. Every site must have one administrator.

Yes

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Approve

Deny

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M-D-Y

Male

Female

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Not a member of the Medical Staff

Active Member

Courtesy Member

Consulting Member

APP Member

AHP Member

Adjunct Member

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Note: Provider will be linked with your group but will retain Epic Hyperspace access

Yes

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Yes

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Yes

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Approve

Deny

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Expand

M-D-Y

Male

Female

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Expand

Not a member of the Medical Staff

Active Member

Courtesy Member

Consulting Member

APP Member

AHP Member

Adjunct Member

reset

Note: Provider will be linked with your group but will retain Epic Hyperspace access

Yes

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Yes

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Yes

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Approve

Deny

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Expand

M-D-Y

Male

Female

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Expand

Not a member of the Medical Staff

Active Member

Courtesy Member

Consulting Member

APP Member

AHP Member

Adjunct Member

reset

Note: Provider will be linked with your group but will retain Epic Hyperspace access

Yes

reset

Yes

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Yes

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Approve

Deny

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Expand

M-D-Y

Male

Female

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Expand

Not a member of the Medical Staff

Active Member

Courtesy Member

Consulting Member

APP Member

AHP Member

Adjunct Member

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Note: Provider will be linked with your group but will retain Epic Hyperspace access

Yes

reset

Yes

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There is no further capacity on this form to add another provider. Please submit another request to add more providers.

Note: Please list all Staff (excluding providers) you would like to have access to EpicCare Link in your practice. The maximum capacity of this form is 5 staff members. If you need to submit more staff members please complete another form.

Approve

Deny

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M-D-Y

Male

Female

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Clinical

NonClinical

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Office Support

Office Manager

Other

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Yes

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Yes

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Yes

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Approve

Deny

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M-D-Y

Male

Female

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Clinical

NonClinical

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Office Support

Office Manager

Other

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Yes

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Yes

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Yes

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Approve

Deny

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M-D-Y

Male

Female

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Clinical

NonClinical

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Office Support

Office Manager

Other

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Expand

Yes

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Yes

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Yes

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Approve

Deny

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Expand

M-D-Y

Male

Female

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Clinical

NonClinical

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Office Support

Office Manager

Other

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Expand

Yes

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Yes

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Yes

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Approve

Deny

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Expand

M-D-Y

Male

Female

reset

Clinical

NonClinical

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Office Support

Office Manager

Other

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Expand

Yes

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Yes

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There is no further capacity on this form to add another staff member. Please submit another request to add more staff.

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True

False

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Required format:

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/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

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