Epic_EAP
Referral Date
Today M-D-Y
* I would like to * must provide value
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)
Site Approval Approve
Deny
Site Denial
*Clinic/Office (Legal Name)* must provide value
* Clinic/Office Primary Contact Name* must provide value
* Email Address for Clinic/Office Primary Contact* must provide value
* Clinic/Office Street Address* must provide value
* Clinic/Office City* must provide value
* Clinic/Office State* must provide value
AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS DC FM GU MH MP PW PR VI
* Clinic/Office Zip* must provide value
Enter a 5 digit Zip Code
* Clinic/Office Primary Phone Number* must provide value
Enter a 10 digit Phone Number
* Clinic/Office Fax Number* must provide value
Enter a 10 digit Fax Number
* The practice needs to:* must provide value
Add a Provider (required for new sites)
Add Clinic Staff (Non-Provider)
Make another change
Site Administrator First Name
Site Administrator Last Name
Site Administrator Email
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. Provider Approval Approve
Deny
Provider Denial
* Provider First Name* must provide value
Provider Middle Initial
If none, please disregard
* Provider Last Name* must provide value
Provider Suffix
* Provider Date of Birth* must provide value
M-D-Y
* Provider Gender* must provide value
Male
Female
* Provider NPI* must provide value
* Provider Medical License Number* must provide value
* Provider Type* must provide value
DDS (Doctor of Dental Surgery) DMD (Doctor of Dental Medicine) DO (Doctor of Osteopathy) DPM (Doctor of Podiatric Medicine) MD (Medical Doctor) OD (Doctor of Optometry) PA (Physician Assistant) NNP (Neonatal Nurse Practitioner) NP (Nurse Practitioner) FNP (Family Nurse Practitioner) ACNP (Acute Care Nurse Practitioner) ANP (Adult Nurse Practitioner) APRN (Advanced Practice Registered Nurse) CFNP (Certified Family Nurse Practitioner) CNM (Certified Nurse Midwife) CPNP (Certified Pediatric Nurse Practitioner) PsyD (Doctor of Psychology) PhD (Doctor of Philosophy) Pharm.D (Doctor of Pharmacy) PNP (Pediatric Nurse Practitioner) DNP (Doctor of Nursing Practice) AUD (Audiologist) WHCNP (Women's Health Care Nurse Practitioner) Other
* Please provide additional detail* must provide value
* What is the provider's current Medical Staff status at Texas Children's Hospital?* must provide value
Not a member of the Medical Staff
Active Member
Courtesy Member
Consulting Member
APP Member
AHP Member
Adjunct Member
Note: Provider will be linked with your group but will retain Epic Hyperspace access *Is provider requesting EpicCare Link Access?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Provider Email* must provide value
Must be a unique email address
* Retype Provider Email (Confirmation)* must provide value
* Add another provider?* must provide value
Yes
No
Provider Approval Approve
Deny
Provider Denial
* Provider First Name* must provide value
Provider Middle Initial
If none, please disregard
* Provider Last Name* must provide value
Provider Suffix
* Provider Date of Birth* must provide value
M-D-Y
* Provider Gender* must provide value
Male
Female
* Provider NPI* must provide value
* Provider Medical License Number* must provide value
* Provider Type* must provide value
DDS (Doctor of Dental Surgery) DMD (Doctor of Dental Medicine) DO (Doctor of Osteopathy) DPM (Doctor of Podiatric Medicine) MD (Medical Doctor) OD (Doctor of Optometry) PA (Physician Assistant) NNP (Neonatal Nurse Practitioner) NP (Nurse Practitioner) FNP (Family Nurse Practitioner) ACNP (Acute Care Nurse Practitioner) ANP (Adult Nurse Practitioner) APRN (Advanced Practice Registered Nurse) CFNP (Certified Family Nurse Practitioner) CNM (Certified Nurse Midwife) CPNP (Certified Pediatric Nurse Practitioner) PsyD (Doctor of Psychology) PhD (Doctor of Philosophy) Pharm.D (Doctor of Pharmacy) PNP (Pediatric Nurse Practitioner) DNP (Doctor of Nursing Practice) AUD (Audiologist) WHCNP (Women's Health Care Nurse Practitioner) Other
* Please provide additional detail* must provide value
* What is the provider's current Medical Staff status at Texas Children's Hospital?* must provide value
Not a member of the Medical Staff
Active Member
Courtesy Member
Consulting Member
APP Member
AHP Member
Adjunct Member
Note: Provider will be linked with your group but will retain Epic Hyperspace access *Is provider requesting EpicCare Link Access?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Provider Email* must provide value
Must be a unique email address
* Retype Provider Email (Confirmation)* must provide value
* Add another provider?* must provide value
Yes
No
Provider Approval Approve
Deny
Provider Denial
* Provider First Name* must provide value
Provider Middle Initial
If none, please disregard
* Provider Last Name* must provide value
Provider Suffix
* Provider Date of Birth* must provide value
M-D-Y
* Provider Gender* must provide value
Male
Female
* Provider NPI* must provide value
* Provider Medical License Number* must provide value
* Provider Type* must provide value
DDS (Doctor of Dental Surgery) DMD (Doctor of Dental Medicine) DO (Doctor of Osteopathy) DPM (Doctor of Podiatric Medicine) MD (Medical Doctor) OD (Doctor of Optometry) PA (Physician Assistant) NNP (Neonatal Nurse Practitioner) NP (Nurse Practitioner) FNP (Family Nurse Practitioner) ACNP (Acute Care Nurse Practitioner) ANP (Adult Nurse Practitioner) APRN (Advanced Practice Registered Nurse) CFNP (Certified Family Nurse Practitioner) CNM (Certified Nurse Midwife) CPNP (Certified Pediatric Nurse Practitioner) PsyD (Doctor of Psychology) PhD (Doctor of Philosophy) Pharm.D (Doctor of Pharmacy) PNP (Pediatric Nurse Practitioner) DNP (Doctor of Nursing Practice) AUD (Audiologist) WHCNP (Women's Health Care Nurse Practitioner) Other
* Please provide additional detail* must provide value
* What is the provider's current Medical Staff status at Texas Children's Hospital?* must provide value
Not a member of the Medical Staff
Active Member
Courtesy Member
Consulting Member
APP Member
AHP Member
Adjunct Member
Note: Provider will be linked with your group but will retain Epic Hyperspace access *Is provider requesting EpicCare Link Access?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Provider Email* must provide value
Must be a unique email address
* Retype Provider Email (Confirmation)* must provide value
* Add another provider?* must provide value
Yes
No
Provider Approval Approve
Deny
Provider Denial
* Provider First Name* must provide value
Provider Middle Initial
If none, please disregard
* Provider Last Name* must provide value
Provider Suffix
* Provider Date of Birth* must provide value
M-D-Y
* Provider Gender* must provide value
Male
Female
* Provider NPI* must provide value
* Provider Medical License Number* must provide value
* Provider Type* must provide value
DDS (Doctor of Dental Surgery) DMD (Doctor of Dental Medicine) DO (Doctor of Osteopathy) DPM (Doctor of Podiatric Medicine) MD (Medical Doctor) OD (Doctor of Optometry) PA (Physician Assistant) NNP (Neonatal Nurse Practitioner) NP (Nurse Practitioner) FNP (Family Nurse Practitioner) ACNP (Acute Care Nurse Practitioner) ANP (Adult Nurse Practitioner) APRN (Advanced Practice Registered Nurse) CFNP (Certified Family Nurse Practitioner) CNM (Certified Nurse Midwife) CPNP (Certified Pediatric Nurse Practitioner) PsyD (Doctor of Psychology) PhD (Doctor of Philosophy) Pharm.D (Doctor of Pharmacy) PNP (Pediatric Nurse Practitioner) DNP (Doctor of Nursing Practice) AUD (Audiologist) WHCNP (Women's Health Care Nurse Practitioner) Other
* Please provide additional detail* must provide value
* What is the provider's current Medical Staff status at Texas Children's Hospital?* must provide value
Not a member of the Medical Staff
Active Member
Courtesy Member
Consulting Member
APP Member
AHP Member
Adjunct Member
Note: Provider will be linked with your group but will retain Epic Hyperspace access *Is provider requesting EpicCare Link Access?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Provider Email* must provide value
Must be a unique email address
* Retype Provider Email (Confirmation)* must provide value
* Add another provider?* must provide value
Yes
No
Provider Approval Approve
Deny
Provider Denial
* Provider First Name* must provide value
Provider Middle Initial
If none, please disregard
* Provider Last Name* must provide value
Provider Suffix
* Provider Date of Birth* must provide value
M-D-Y
* Provider Gender* must provide value
Male
Female
* Provider NPI* must provide value
* Provider Medical License Number* must provide value
* Provider Type* must provide value
DDS (Doctor of Dental Surgery) DMD (Doctor of Dental Medicine) DO (Doctor of Osteopathy) DPM (Doctor of Podiatric Medicine) MD (Medical Doctor) OD (Doctor of Optometry) PA (Physician Assistant) NNP (Neonatal Nurse Practitioner) NP (Nurse Practitioner) FNP (Family Nurse Practitioner) ACNP (Acute Care Nurse Practitioner) ANP (Adult Nurse Practitioner) APRN (Advanced Practice Registered Nurse) CFNP (Certified Family Nurse Practitioner) CNM (Certified Nurse Midwife) CPNP (Certified Pediatric Nurse Practitioner) PsyD (Doctor of Psychology) PhD (Doctor of Philosophy) Pharm.D (Doctor of Pharmacy) PNP (Pediatric Nurse Practitioner) DNP (Doctor of Nursing Practice) AUD (Audiologist) WHCNP (Women's Health Care Nurse Practitioner) Other
* Please provide additional detail* must provide value
* What is the provider's current Medical Staff status at Texas Children's Hospital?* must provide value
Not a member of the Medical Staff
Active Member
Courtesy Member
Consulting Member
APP Member
AHP Member
Adjunct Member
Note: Provider will be linked with your group but will retain Epic Hyperspace access *Is provider requesting EpicCare Link Access?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Provider Email* must provide value
Must be a unique email address
* Retype Provider Email (Confirmation)* must provide value
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. Staff Approval Approve
Deny
Staff Denial
* Staff First Name* must provide value
Staff Middle Initial
If none, please disregard
* Staff Last Name* must provide value
Staff Suffix
* Staff Date of Birth* must provide value
M-D-Y
* Staff Gender* must provide value
Male
Female
* Staff Email* must provide value
Must be a unique email address
* Retype Staff Email (Confirmation)* must provide value
* Please indicate type of access requested, based on job role* must provide value
Clinical
NonClinical
* NonClinical Staff Role* must provide value
Office Support
Office Manager
Other
* Please provide additional detail* must provide value
* Clinical Staff Role* must provide value
CMA (Certified Medical Assistant) CRNA (Certified Registered Nurse Anesthetist) CSA (Certified Surgical Assistant) LCSW (Licensed Clinical Social Worker) LD (Licensed Dietitian) LPC (Licensed Professional Counselor) LSA (Licensed Surgical Assistant) LVN (Licensed Vocational Nurse) RN (Registered Nurse) RNFA (Registered Nurse First Assistant) RD (Registered Dietitian) RDA (Registered Dental Assistant) Phleb (Phlebotomy) R.Ph. (Registered Pharmacist) CGC (Certified Genetic Counselor) OT (Occupational Therapist) LMSW (Licensed Master of Social Work) RC (Referral Coordinator) PT (Physical Therapist) ST (Speech Therapist) CLS (Child Life Specialist) Other
License Number, If Applicable
* Please provide additional detail* must provide value
* Have you ever worked for Texas Children's or any of its affiliates?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Add another staff member?* must provide value
Yes
No
Staff Approval Approve
Deny
Staff Denial
* Staff First Name* must provide value
Staff Middle Initial
If none, please disregard
* Staff Last Name* must provide value
Staff Suffix
* Staff Date of Birth* must provide value
M-D-Y
* Staff Gender* must provide value
Male
Female
* Staff Email* must provide value
Must be a unique email address
* Retype Staff Email (Confirmation)* must provide value
* Please indicate type of access requested, based on job role* must provide value
Clinical
NonClinical
* NonClinical Staff Role* must provide value
Office Support
Office Manager
Other
* Please provide additional detail* must provide value
* Clinical Staff Role* must provide value
CMA (Certified Medical Assistant) CRNA (Certified Registered Nurse Anesthetist) CSA (Certified Surgical Assistant) LCSW (Licensed Clinical Social Worker) LD (Licensed Dietitian) LPC (Licensed Professional Counselor) LSA (Licensed Surgical Assistant) LVN (Licensed Vocational Nurse) RN (Registered Nurse) RNFA (Registered Nurse First Assistant) RD (Registered Dietitian) RDA (Registered Dental Assistant) Phleb (Phlebotomy) R.Ph. (Registered Pharmacist) CGC (Certified Genetic Counselor) OT (Occupational Therapist) LMSW (Licensed Master of Social Work) RC (Referral Coordinator) PT (Physical Therapist) ST (Speech Therapist) CLS (Child Life Specialist) Other
License Number, If Applicable
* Please provide additional detail* must provide value
* Have you ever worked for Texas Children's or any of its affiliates?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Add another staff member?* must provide value
Yes
No
Staff Approval Approve
Deny
Staff Denial
* Staff First Name* must provide value
Staff Middle Initial
If none, please disregard
* Staff Last Name* must provide value
Staff Suffix
* Staff Date of Birth* must provide value
M-D-Y
* Staff Gender* must provide value
Male
Female
* Staff Email* must provide value
Must be a unique email address
* Retype Staff Email (Confirmation)* must provide value
* Please indicate type of access requested, based on job role* must provide value
Clinical
NonClinical
* NonClinical Staff Role* must provide value
Office Support
Office Manager
Other
* Please provide additional detail* must provide value
* Clinical Staff Role* must provide value
CMA (Certified Medical Assistant) CRNA (Certified Registered Nurse Anesthetist) CSA (Certified Surgical Assistant) LCSW (Licensed Clinical Social Worker) LD (Licensed Dietitian) LPC (Licensed Professional Counselor) LSA (Licensed Surgical Assistant) LVN (Licensed Vocational Nurse) RN (Registered Nurse) RNFA (Registered Nurse First Assistant) RD (Registered Dietitian) RDA (Registered Dental Assistant) Phleb (Phlebotomy) R.Ph. (Registered Pharmacist) CGC (Certified Genetic Counselor) OT (Occupational Therapist) LMSW (Licensed Master of Social Work) RC (Referral Coordinator) PT (Physical Therapist) ST (Speech Therapist) CLS (Child Life Specialist) Other
License Number, If Applicable
* Please provide additional detail* must provide value
* Have you ever worked for Texas Children's or any of its affiliates?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Add another staff member?* must provide value
Yes
No
Staff Approval Approve
Deny
Staff Denial
* Staff First Name* must provide value
Staff Middle Initial
If none, please disregard
* Staff Last Name* must provide value
Staff Suffix
* Staff Date of Birth* must provide value
M-D-Y
* Staff Gender* must provide value
Male
Female
* Staff Email* must provide value
Must be a unique email address
* Retype Staff Email (Confirmation)* must provide value
* Please indicate type of access requested, based on job role* must provide value
Clinical
NonClinical
* NonClinical Staff Role* must provide value
Office Support
Office Manager
Other
* Please provide additional detail* must provide value
* Clinical Staff Role* must provide value
CMA (Certified Medical Assistant) CRNA (Certified Registered Nurse Anesthetist) CSA (Certified Surgical Assistant) LCSW (Licensed Clinical Social Worker) LD (Licensed Dietitian) LPC (Licensed Professional Counselor) LSA (Licensed Surgical Assistant) LVN (Licensed Vocational Nurse) RN (Registered Nurse) RNFA (Registered Nurse First Assistant) RD (Registered Dietitian) RDA (Registered Dental Assistant) Phleb (Phlebotomy) R.Ph. (Registered Pharmacist) CGC (Certified Genetic Counselor) OT (Occupational Therapist) LMSW (Licensed Master of Social Work) RC (Referral Coordinator) PT (Physical Therapist) ST (Speech Therapist) CLS (Child Life Specialist) Other
License Number, If Applicable
* Please provide additional detail* must provide value
* Have you ever worked for Texas Children's or any of its affiliates?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. * Add another staff member?* must provide value
Yes
No
Staff Approval Approve
Deny
Staff Denial
* Staff First Name* must provide value
Staff Middle Initial
If none, please disregard
* Staff Last Name* must provide value
Staff Suffix
* Staff Date of Birth* must provide value
M-D-Y
* Staff Gender* must provide value
Male
Female
* Staff Email* must provide value
Must be a unique email address
* Retype Staff Email (Confirmation)* must provide value
* Please indicate type of access requested, based on job role* must provide value
Clinical
NonClinical
* NonClinical Staff Role* must provide value
Office Support
Office Manager
Other
* Please provide additional detail* must provide value
* Clinical Staff Role* must provide value
CMA (Certified Medical Assistant) CRNA (Certified Registered Nurse Anesthetist) CSA (Certified Surgical Assistant) LCSW (Licensed Clinical Social Worker) LD (Licensed Dietitian) LPC (Licensed Professional Counselor) LSA (Licensed Surgical Assistant) LVN (Licensed Vocational Nurse) RN (Registered Nurse) RNFA (Registered Nurse First Assistant) RD (Registered Dietitian) RDA (Registered Dental Assistant) Phleb (Phlebotomy) R.Ph. (Registered Pharmacist) CGC (Certified Genetic Counselor) OT (Occupational Therapist) LMSW (Licensed Master of Social Work) RC (Referral Coordinator) PT (Physical Therapist) ST (Speech Therapist) CLS (Child Life Specialist) Other
License Number, If Applicable
* Please provide additional detail* must provide value
* Have you ever worked for Texas Children's or any of its affiliates?* must provide value
Yes
No
*Are you the site administrator* must provide value
Yes
No
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. There is no further capacity on this form to add another staff member. Please submit another request to add more staff. * Please describe change requested. To remove users from EpicCare Link, see your Site Administrator.
* must provide value
* Submitter's First Name* must provide value
Submitter's Middle Initial
If none, please disregard
* Submitter's Last Name* must provide value
* Submitter's Email* must provide value
Must be a unique email address
* Retype Submitter's Email (Confirmation)* must provide value
* Submitter's Primary Phone Number* must provide value
Enter a 10 digit Phone Number