Access request form for Aspirus EpicLink:
If your facility currently has EpicLink access, please contact your site administrator.
Site Demographics:
Site Name: *
Address: *
City: *
State: *
ZIP Code: *
Phone Number: *
Fax Number: *
Type of Facility: *
Describe Purpose for EpicLink Access: *
Is your organization currently connected to an HIE (Health Information Exchange)? *
Yes
No
If yes, which HIE is being used?
Estimated number of users needing EpicLink access: *
Site Administrator Information:
Name: *
Title: *
Email (Must be corporate or work email address): *
Phone Number: *
