EpicCare Link Account Enrollment and Agreement Form New Practice

St. Charles Health System EpicCare Link Program
Account Enrollment and Agreement Form
New Practice

EpicCare Link is open to any licensed medical provider and/or their staff to access records for referred St. Charles' patients
If setting up a new practice, you will need the following:

A single enrollee who is a licensed provider with a registered NPI
An Authorized Representative (Administrator) will function in the following way:

Maintain the practice user group list
Perform annual verification of members (or at the request of St. Charles Health System
Act as the subject matter expert
If at any time, this authorized representative is replaced, you are to notify xxx

The practice must be identified on the State of Oregon website http://egov.sos.state.or.us/br/pkg_web_name_srch_inq.login.
Complete the sections on the attached External User Agreement

The enrollment process typically takes two weeks, depending upon the time of year (annual enrollment may cause a longer delay). If you need immediate access to a St. Charles patient record, please contact our HIM department at 541-706-7784, option 1.
If, for any reason, this form is not completed accurately, the form will be returned with a reason to the originator to be resubmitted

Secure email accounts only (e.g. Gmail or Yahoo, etc., not allowed)
No PO Boxes
The practice must be identified on the State of Oregon website
NPI and license nos. are required for providers. Non-providers enter N/A

Date*

First Name*	Middle Initial*

Last Name:*

Date of Birth*

Job Title*

Email*

Home address*


City*	State*


Postal Code*	Office phone*

Practice Name*	Practice Address*

Practice City*	Practice State*


Practice Zip*

Provider NPI No.*	Medical License No.*

Administrator*	Administrator Email*


Administrator Phone No.*

Entity website URL*

Have you ever had an EpicCare Link account from another organization?*

Yes

If so, where and when?

St. Charles Health System (SCHS) authorizes access to our electronic health records in accordance with state and federal law, including HIPAA and the HITECH Act.

Please state your reason for requesting electronic access to SCHS medical records*

To help us evaluate your request, please check all of the following that apply and provide an explanation where required:

TREATMENT

We have one or more SCHS credentialed providers in our organization

Credentialed Provider Name(s)

We admit or refer patients to/from SCHS

We order labs, diagnostic imaging or procedures from SCHS

Other (explanation required)

PAYMENT

We bill and/or provide operational support for a SCHS credentialed physician/office and have a business associate agreement (BAA) in place with that office

We conduct state or federally required audits (HEDIS, Risk Adj., CCO, etc.) and need access to SCHS records for the period of:

From

Other

If other, please explain:

OPERATIONS

We provide care coordination/case management for patients who have a SCHS health record

We provide quality and outcomes assessments for patients who have a SCHS health record

We provide peer review for shared patients who have a SCHS health record

We use a secure email server (e.g. Gmail or Yahoo, etc., is not allowed)

Other

If other, please explain (required)

ADDITIONAL INFORMATION ABOUT YOUR ORGANIZATION

Choose All That Apply

We are a covered entity as defined by HIPAA (See www.cms.gov, “Are You a Covered Entity?”)

We have a contract or BAA in place with SCHS and/or a SCHS entity

We have a HITECH compliant breach notification process in place

Privacy Officer Contact Name*

Privacy Officer Phone Number

Security Officer Contact Name

Security Officer Phone Number

Will any of the SCHS information you access be disclosed to a third party (excluding any federal or state agencies as required by law)?

Yes

If yes, please explain:

By selecting the “I accept” button, you acknowledge that you have read and acknowledge the terms of the EUA and that you are signing this agreement electronically.

I accept the agreement

Initial*