Epic Link Registration

Type of Organization *

Please enter the information of the organization that is requesting access in the fields provided below.

Organization Name *

Organization Address 1 *

Organization Address 2

Organization City *

Organization State *

Organization Zip or Postal Code *

Organization Phone *

Organization Fax

Is your Organization already active on University Health’s Epic Link portal? *

Please enter the information of the person requesting access in the fields provided below.

Requestor First Name *

Requestor Last Name *

Requestor Job Title *

Requestor Email Address *

Requestor Phone *

address1