St Charles Health System

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
    • 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
First Name* Middle Initial*
Date of Birth*
Home address*
City* State*
Postal Code* Office phone*
* *
Practice City* Practice State*
Practice Zip*
Provider NPI No.* Medical License No.*
Administrator* Administrator Email*
Administrator Phone No.*
Have you ever had an EpicCare Link account from another organization?*

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:






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

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.