Request Access to EpicCare Link at UConn Health

Name*

First Last

Full Legal Name of Organization*

Address*

Street Address Address Line 2 City State ZIP Code

Position/Job Title

Phone*

Fax

Email*

Why does your organization wish to access EpicCare Link?

Patient Care

I am a health care provider and wish to access my patients’ UConn Health records for treatment purposes.

Research

Who is the UConn Health contact for this trial or project?

Does this research project have UConn Health IRB approval?

Does your organization currently access UConn Health PHI?

If yes, who is your point of contact for PHI requests?

Does your organization use Epic?

Is your organization a Covered Entity under HIPAA?

Does your organization currently have an agreement to provide services to UConn Health?

Does your organization have a Business Associate Agreement with UConn Health?

Who is your contact at UConn Health?

Name

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EpicCare Link at UConn Health Registration