Epic Link Request Access Form

To obtain John Muir Health Link access, providers and staff should work with their practice manager or other practice representative to complete this form.

PLEASE NOTE: This form is intended for MSO products and customers only. If you are experiencing a medical emergency, please call 911.

Request Type

--Select-- New Access Removal of Access

Practice Information

*Organization Name

Practice Alias

Specialty

Address

City

Zip Code

Tax ID

Practice Contracted with JMHPN?

--Select-- Yes No Unknown

Authorization Information

*Requestor Name

Phone (xxx-xxx-xxxx)

*Email

*Title

Date (mm/dd/yyyy)

Relation to User(s)

*By checking this box, I confirm that I am authorized to make this request.

User/Provider Information

*First Name

*Last Name

NPI (If Applicable)

*Title/Role

Provider Manager Clinical Staff Admin Staff

*Phone Number (xxx-xxx-xxxx)

Address

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Office phone number (xxx-xxx-xxxx)

Office fax number (xxx-xxx-xxxx)

Tax ID

*Email

Reset

Submit