EpicCare Link Request for Access Form

EpicCare Link Access Request

Thank you for your interest in gaining access to EpicCare Link at Children’s of Alabama. Please complete the following information and a team member will follow up with you regarding access to the system.

EpicCare Link is a tool that provides real-time web access to patient information so you can access patients' clinical data and communicate with Children’s of Alabama to provide quality patient care. You can also use EpicCare Link to quickly refer patients to our organization.

Practice Name

Practice Phone Number

Practice Address

Address 2

Practice City/Town

Practice State/Province

Practice ZIP/Postal Code

Which of the following best describes your type of healthcare facility?

Please list the specialty

Practice Web Site (if available)

Practice EMR- (Athena, Greenway Health, etc.)

Practice Fax Number

How did you find out about the EpicCare Link at Children’s of Alabama?

Site Administrator Information

EpicCare Link is a collection of different web pages, or activities, that correspond to different tasks. The activity that you use depends on what you want to accomplish.

Each practice is asked to identify a Site Administrator to serve as the manager of all users at your clinical practice site. Some of the duties of the Site Administrator will be to request and process new accounts for your staff and change passwords for your users and unblock users.

Please complete the section below for the Site Administrator and a backup in case of staff changes, availability, etc.

Once you click the submit button, your information will be sent to the Children’s of Alabama EpicCare Link Information Technology Team for review.

First Name

Middle Name or Initial

Last Name

Suffix

Site Administrator Title

Site Administrator Email Address

Site Administrator Alternative Information

Site Administrator Alternate First Name

Site Administrator Alternate Middle Name or Initial

Site Administrator Alternate Last Name

Suffix

Site Administrator Alternate Title

Site Administrator Alternate Email Address

Locations

Patients & Visitors

Ways to Give

EpicCare Link Access Request

Site Administrator Information

Site Administrator Alternative Information

I WANT TO...

PATIENTS

PHYSICIANS

MEDIA

AWARDS & RECOGNITION

CONNECT