ECL Request - ECL

EpicCare Link New Site Request

Northwestern Memorial HealthCare (NMHC)'s computer network and applications are an essential part of patient care, payment and operations (TPO). I understand that my staff will be using NMHC's network as their job relates to TPO. Access to and use of information systems are covered under appropriate NMHC security and privacy policies.

As a covered entity under HIPAA I agree to the following when requesting my staff to have access to NMHC's protected health information (PHI):

I agree to provide periodic security and privacy training for my staff that use NMHC’s Information Systems.
I agree to require each user to complete a background check pursuant to NMHC’s policies. I will provide the results to NMHC upon their request.
I agree to take all reasonable precautions to assure that the PHI entrusted to my staff will be accessed only on a "need to know" and "minimum necessary" basis, that it will not be disclosed to unauthorized persons, and will not be used for personal purposes.
I agree to request individual access for each staff member that needs to access NMHC network resulting in each staff member having their own individual logon and password.
I agree that my staff will not share passwords.
I understand that my staff's access will be disabled when their account has not been used in 90 days and my staff will have to contact Information Security to have their access reinstated. I also understand that their access will be terminated after 6 months of non-use.
I agree to notify or have my designee notify the NMHC Information Security Department by contacting the NMHC Service Desk 312.926.4357 within one week of departure, when my staff with system access terminates from my employment. I will not re-use ID and passwords from terminated individuals on existing or new employees.
I acknowledge that I retain the legal responsibility to identify my staff if there are any questionable incidents needing investigation and agree to cooperate fully with any investigation that may occur.
My organization will be accountable for any inappropriate activity regarding privacy and\or security breaches by my staff. This may include removal of access privileges and notification of the appropriate authorities as deemed necessary.
I agree to promptly report all known or suspected violations to the CISO, Northwestern Medicine's Chief Information Security Officer, at ITSOC@nm.org.

I agree

NOTE: Before submitting the below request for EpicCare Link (View Only), Full Epic access is only available to credentialed physicians, nurse practitioners, and physician assistants with membership and/or privileges approved through a Northwestern Medicine hospital. To request application to apply for privileges at a Northwestern Medicine hospital, contact MSadmin@nm.org.

(*) Required fields

Organization Information

* Organization Name

Tax ID/FEIN Number for your Agency (This information will help uniquely identify your agecncy in our system)

Practice Specialty if applicable (optional)

Office Demographics

* Street Address

* City

* State

* Zip

* Office Phone Number

Fax Number

Site Administrator

Referring Physician

Every Epic Care Link organization requires a site administrator to submit new user requests and user termination requests.

* First Name

* Last Name

Middle Initial

* Email (Cannot be a shared, please provide unique email address. Business email preferred if applicable)

* Mobile Number (Required for Microsoft Authenticator Self-Service Password Reset)

* Date of Birth (MM/DD/YYYY)

Northwestern Medicine ID (optional)

* NPI#

* State License Number

Sponsoring Physician or NM Manager

Please note, this individual must be in Northwestern Medicine's HR system for your submission to be approved. He / she will act as validation that your organization has an established relationship with Northwestern Medicine.

Sponsoring Physician or NM Manager (A Manager or above, must be a NM Employee)

Please note, this individual must exist in Northwestern Medicine's HR system as a Manager or above in order for your submission to be approved. He / She will need to validate that your organization has an established relationship with Northwestern Medicine.

* First Name

* Last Name

* Email(Cannot be a shared, please provide unique email address)

* Phone Number

Northwestern Medicine ID (optional)

Additional Physicians at Organization (if applicable)

This information will not be used to grant additional access, but will allow us to auto-populate a patient list based on event triggers in our Epic system. If you do not complete this section, you and your staff members will need to manually search our database with each patient's full name, DOB, and gender to gain access to specific patients.

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