Fillable User Access & Updates Request Form Community Provider

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User Access & Updates Request Form Community Provider

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8/4/2020
User Access & Updates Request Form
Community Provider and Staff
This section must be completed by the Supervisor or Manager of the facility.
Supv/Mgr Name:
Phone Number:
Supv/Mgr Email:
Date Requested:
Facility Name:
Detailed description of requesting user's job duties for accessing this site: (Required for access)
Have you had access to any of our facilities portals in the past:
No
Type of Request: New Account Request
Update Current Account Deactivate Access
Other, please explain:
Yes
Physician/Provider
Clinical Support Staff (only RN, LPN/LVN, MA, Surgical/Referral Schedulers)
Psych Professional
Front Desk
End Date
CareLink Help Desk 855-525-8770 Page 1 of 2
Other, please explain:
1. The request should be submitted to the CareLink Access Team by your
Supervisor or Manager.
2. Requests may not be submitted on behalf of oneself.
3. If you are a Physician or Provider, complete Section A and Section C.
4. If you are not a Physician or Provider, complete Section A, Section B (if
applicable), and Section D.
5. All Medical Practices: for accurate and complete patient lists in CareLink,
please attach a full provider roster for your location.
This is a writeable PDF form. Fill out one form per requestor, save and E-mail completed forms to:
AMACareLinkaccess@ardenthealth.com
SECTION A: This section MUST be completed in FULL for EVERY request.
Note: If requesting a new account and this person is replacing an existing account (e.g. former
employee), please list
name(s) that should be deactivated here:
The requesting user will access the portal as a (choose ONLY one that best encompasses their job role):
Biller/Coder
(Is this a 3rd party billing company employee? Yes
Research Study Monitor
Chart Prep Clerk
Management
Clinical/Medical Student Rotation Start Date
No If yes, is there a business associate agreement place? Yes No
Insurance Company Rep Audit Staff (Audit Staff must submit a list of patients they are requesting chart access for)
Provider Requesting Access Section – this section is for providers/physicians only.
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
Section D: Staff Requesting Access Section – this section is for all non-provider users.
Last Name & Suffix: (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) :
Continued Care Service Coordination (CCSC) applicants - if your location accept patients via
Referral fr
o
m our facilities Case Management, please select one of the choices below.
Insurance Company Rep Case Management/Utilization/Claims Staff Insurance Company Rep Audit Staff
Health Insurance Company applicants - please select the choice below that best encompasses your job role.
Patient search will be limited t
o those patients affiliated with your health plan.
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
Page 2 of 2
User Access & Updates Request Form
Community Provider and Staff
SECTION B:
SECTION C:
Secure Direct HISP Address - this section is for providers/physicians only.
(e.g. bwells@direct.aclinic.org - this is not an email address. Contact your Helpdesk for your direct address.
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User Access & Updates Request Form Community Provider

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Completed 30 July 2021

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