Fillable User Access & Updates Request Form Community Provider (Lovelace Health System)

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User Access & Updates Request Form Community Provider (Lovelace Health System)

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This is a writeable PDF form. Fill out one form per requestor, save and E-mail completed forms to:
ABQCareLinkAccess@ardenthealth.com
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 reect a private professional email
(i.e. sally.jones@privatepractice.com).
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:
https://nppes.cms.hhs.gov/NPPESRegistry.
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
Physician/Provider
Clinical Support Staff (only RN, LPN/LVN, MA, Surgical/Referral Schedulers)
Psych Professional
Front Desk
Biller/Coder
Research Study Monitor
Chart Prep Clerk
Management
Clinical/Medical Student Rotation Start Date End Date
Other, please explain:
CareLink Help Desk: 855-525-8770 5/7/19
CareLink Help Desk: 855-525-8770 5/7/19
Continued Care Service Coordination (CCSC) applicants - if your location accept patients via Referral from our
facilities Case Management, please select one of the choices below.
CCSC- Vendor Staff (Referral Acceptance Staff Only for - DME, IV Infusion, Outpatient Therapy/Rehab, Dialysis)
CCSC- Clinical Staff (Admission Staff & Backup Only for - Home Health Care, Home Hospice, SNF/NH, LTAC, Acute
Rehab)
CCSC - Pharmacist (Pharmacists Only for - Home Health Care, Home Hospice, SNF/NH, LTAC, Acute Rehab
Health Insurance Company applicants - please select the choice below that best encompasses your job role.
Patient search will be limited to those patients afliated with your health plan.
Insurance Company Rep Case Management/Utilization/Claims Staff Insurance Company Rep Auditor Staff
Provider Requesting Access Section – this section is for providers/physicians only
Last Name & Sufx: (Sr, Jr, III, etc.) First Name: (As appears on Medical License) MI:
Title: (MD, DO, CFNP etc.) Provider Billing Number (NPI): DEA Number:
Professional email: Last 4 digits of SS#: Gender: M F
Provider Billing Specialty: Provider Billing Taxonomy:
State License Number: License Exp Date:
Practice Name:
Address:
Address 2:
City State: Zip
Phone: Fax: Preferred Communication Method:
In Basket Message Fax
Staff Requesting Access Section – this section is for all non-provider users.
Last Name & Sufx: (Sr, Jr, III, etc.) First Name: MI: Gender:
M F
Credentials: (RN, MA, LPN, etc.) Job Title/Role: Last 4 digits of SS#:
Practice Name: Address:
Address 2:
City: State: Zip:
Phone: Fax: Professional email:
User Context Number: (Internal use)
Secure Direct HISP Address - this section is for providers/physicians only
(e.g. b.wells@direct.aclinic.org – this is not an email address. Contact your Helpdesk for your direct address.)
Direct Address:
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User Access & Updates Request Form Community Provider (Lovelace Health System)

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Completed 8 April 2021

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