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

Practice Information

*Organization Name

Practice Alias

Specialty

Address

City

Zip Code

Tax ID

Practice Contracted with JMHPN?

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

*Phone Number (xxx-xxx-xxxx)

Address

City

State

Zip Code

Office phone number (xxx-xxx-xxxx)

Office fax number (xxx-xxx-xxxx)

Tax ID

*Email