Epic Link Registration
Type of Organization
*
Organization Information
Please enter the information of the organization that is requesting access in the fields provided below.
Organization Name
*
Organization Phone
*
Please enter a valid phone number.
Organization Fax
*
Please enter a valid fax number.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your organization already active on Sparrow Health Systems Epic Link portal?
*
Please Select
Yes
No
Office Manager/Authorized Requestor
Please enter the information of the person requesting access in the fields provided below.
Office Manager/Authorized Requestor Name
*
First Name
Last Name
Office Manager/Authorized Requestor Job Title
*
Office Manager/Authorized Requestor Email Address
*
example@example.com
Office Manager/Authorized Requestor Phone
*
Please enter a valid phone number to support MFA.
Provider Information
Who needs new/updated access.
Name
*
Legal First Name
Legal Middle Name
Legal Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Role
National Provider Identification Number
Clinical Title
Mirror Access to
Effective Date
-
Month
-
Day
Year
When is access needed by?
Additional Comments
Please verify that you are human
*
Submit
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