CareLink Application Form

Care Link Application Form

This form is intended for new entity/business requests to obtain access to Catholic Health Care Link. Entities/businesses with existing access to Catholic Health Care Link should have their site administrator submit new user account requests via the Admin section in Epic Care Link. Catholic Health Care Link is a secure, web-based application for connecting community partners, payers, and providers to real-time patient information at Catholic Health. It gives you 24/7 access to your patients' medical records. Access includes:

Real-time access to patient encounters, notes, labs, imaging, referrals, and documents
Messaging with Catholic Health staff
Placing Referral Orders to Catholic Health providers
Notifications for patient events, such as admissions and discharges

Submitted applications will be reviewed within 10-14 business days. Approved applicants will be informed by their Catholic Health sponsor and will receive their login credentials from them.

Enter an email address to receive the notification that this application has been submitted.

A valid email is required for notification of submission.

Entity/Business Legal Name

Entity/Business Legal Name is required.

Specialty (required for Providers/Practices)

Street Address

Street Address is required.

Apt/Suite/Office

City

City is required.

State

State is required.

Zip

Zip is required.

Site Phone Number

Site Phone Number is required.

Fax Number

Tax ID

Practice Website

Catholic Health Sponsor

First Name

Sponsor's First Name is required.

Last Name

Sponsor's Last Name is required.

Title

Sponsor's Title is required.

Department

Sponsor's Department is required.

Facility

Sponsor's Facility is required.

Email Address

Valid Email Address is required.

Phone Number

Sponsor's Phone Number is required.

Primary Site Administrator

The Site Administrator is an administrator or site director or a physician and serves as the central point of contact for your account. They should be generally available to all staff during normal business hours.

First Name

Administrator's First Name is required.

Last Name

Administrator's Last Name is required.

Title

Administrator's Title is required.

Street Address

Street Address is required.

Apt/Suite/Office

City

City is required.

State

State is required.

Zip

Zip is required.

Email Address

Email Address is required.

Work Phone Number

Work Phone Number is required.

License Number

NPI (If Applicable)

Is there a Secondary Site Administrator?

Yes

Is Site Administrator the same as Organization Primary Contact?

Yes

Secondary Site Administrator

First Name

Administrator's First Name is required.

Last Name

Administrator's Last Name is required.

Title

Administrator's Title is required.

Street Address

Street Address is required.

Apt/Suite/Office

City

City is required.

State

State is required.

Zip

Zip is required.

Email Address

A valid email Address is required.

Work Phone Number

Work Phone Number is required.

License Number

NPI (If Applicable)

Organization Primary Contact

First Name

Administrator's First Name is required.

Last Name

Administrator's Last Name is required.

Email Address

Email Address is required.

Work Phone Number

Work Phone Number is required.

Please describe the functions your site will perform using Catholic Health's Care Link (Example: Chart review, View images):

Please describe the functions your site will perform using Catholic Health's Care Link.