This is a writeable PDF form. Fill out one form per requestor, save and E-mail completed forms to:
This Access Request MUST be completed by a Supervisor or Manager.
User Access & Updates Request Form
Community Provider and Staff Portal
• Patient lists in CareLink are dependent on having a full provider roster loaded. Medical practices
must provide a complete provider roster for their location. Please attach to the email with your Access
Request Form(s). Please provide all of the information to avoid delays.
• Required for every request:
o Valid email address. This must reect a private professional email
o The last 4 digits of your SS#. This will be used as your security question validation.
o Phone and Fax numbers.
• Required for every Provider request:
o The NPI and Taxonomy elds. The NPI, Taxonomy can be found on this website:
o The Preferred Communication Method eld. Providers can choose whether they want to receive
their communications via fax or from inside the CareLink InBasket.
o The provider’s Direct Address eld. Direct addresses look similar to an email address and provide
a secure, HIPAA-compliant method of transmitting patient health information.
This section must be completed by Supervisor or Manager of the facility
Supv/Mgr Name: Phone Number: Supv/Mgr Email:
Date Requested: Facility Name:
Detailed Description of job duties for accessing this site: (Required for access)
Have you had access to any of our facilities portals in the past: Yes No
Type of Request: New Account Request Update Current Account Deactivate Access
Note: If requesting a new account and this person is replacing an existing account (i.e. former employee), please list name(s) that should
be deactivated here:
I will be accessing the Portal as a (choose the access that best encompasses your job role): CHOOSE ONLY ONE
Clinical Support Staff (only RN, LPN/LVN, MA, Surgical/Referral Schedulers)
Research Study Monitor
Chart Prep Clerk
Clinical/Medical Student Rotation Start Date End Date
Other, please explain:
CareLink Help Desk: 855-525-8770 5/7/19