St Charles Health System

St. Charles Health System EpicCare Link Program
Account Enrollment and Agreement Form
Existing 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 an existing practice, you will need the following:
    • Provide your information below, including your home address (no PO boxes)
      • Your home address is used for auditing purposes
    • Verify the practice name as identified on the State of Oregon website:
      http://egov.sos.state.or.us/br/pkg_web_name_srch_inq.login
    • Enter your authorized representative (Administrator) information in the last three fields.
    • 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*
    *
    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*

    Please initial all statements below:

    I understand that I may not access my personal medical records, including lab results and x-ray reports.
    To obtain copies of my medical records, I will sign an authorization form available from the SCHS Health
    Information Management department.

    *

    I understand that I may not access the medical records of my family members, coworkers, or acquaintances unless I am required as part of my job to obtain information for the care of that patient.

    *

    I will comply with the Minimum Necessary Standard when accessing medical records.

    *

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

    *