LVHN EpicCare Link Enrollment (Practice) Form

Section 1:

Please complete the following form reading all directions where available to initiate enrolling your practice or company in LVHN Link.

The directions contain specific information essential to expedite your enrollment.

Section 2:  Practice Providers if applicable

Please complete the following for each referring provider, include the SUI if they have one already assigned.  Please add additional rows as needed.

Section 3:  Staff Users

Please complete the following for each sfaff member (non-providers) requesting access to LVHN Link.  Include the SUI if they have one already assigned.  Please add additional rows as needed.

Section 4:  User Administrator

Each practice or company must designate at least one user as the LVHN Link User "Site Manager".  This person must be approved by the physician of record.  Please complete the following for the User "Site Manager" designee for your practice.

The section below must be completed by the provider signatory of record for this organization.

Section 5:  Provider Designation of User Administrator

I understand Lehigh Valley Health Network requires each organization to designate a person to be certified as the LVHN Link User Administrator who will be responsible for managing user accounts and ensuring privacy and security compliance.  I hereby designate the individual named in Section 4 as the LVHN Link User Administrator for my organization.