University Health Application for Discharge Placement Access

Applicant Information

*Last Name: *First Name: Middle Name:
*Date of Birth (e.g. 1/2/87): *Email:
*Provider Type (e.g. MD, DO, NP, PA): Specialty:
Provider NPI: *Provider SSN:
*Phone # (e.g. 123-456-7890): Fax #:

Organization Information

*Organization Name: DBA (Doing Business As):
*Mailing Address: *City: * *Zip:
Billing Address: City: Zip:
Organization NPI: *Phone #: Fax #:
*Reason for Access:

By clicking the submit button below, I, the applicant, certify that I am not excluded, debarred, or have been sanctioned by any Federal, State, Licensing authority or other agency with regulatory authority and have current and active privileges to practice medicine in the State of Louisiana. If at any point the previously stated comes into question, I   understand I will lose my access. I also understand that my access within Epicare Link will be audited at any time for any reason. I acknowledge any misuse or abuse of the system   will result in loss of access to the system. Failure to properly fill out this form in its entirety will result in either delay of access, or denial of access to the system. I also agree to   follow all University Health Information Technology (IT) and University Health HIPAA Policies and Procedures.