MemorialCare Link - ROI Account Request

NEW ROI ACCOUNT REQUEST FORM - STEP 1 OF 2

MemorialCare Case Manager or Referring Contact Information

Please enter the following information for the MemorialCare Case Manager or referring party that contacted you.

Name:

First Name

Last Name

Phone:

- -

Email:

Hospital you are requesting information from:

Company Information

Your Company Name:

Office Name:

(you may add additional offices against this account after initial office is setup)

Street Address:

Suite:

City:

State: Zip:

Office Main Phone:

- -

Office Main Email:

Site Admin: Main Contact Person For This Account

Site Administrator Role Responsibilities:

Is the central point of contact for your account
Should be familiar with MemorialCare Link
Should be generally available to all staff during normal business hours
Will be able to reset passwords for all staff
The Site Admin is usually the practice manager, office manager or supervisor

The Site Admin will automatically be added as a user for this account.
Do NOT list again in the Additional Users section below.

First Name:
Last Name:
Phone:	- -
Email:
Job Title:
End User License Agreement (EULA):
Site Admin has read EULA View EULA

Additional Users (Optional)

(People who need access in addition to Site Admin listed above. All fields but email are required.)

	First	Last	Phone		Email	Job Title	Read EULA
1)			-	-
2)			-	-
3)			-	-
4)			-	-
5)			-	-

This product includes SNOMED Clinical Terms® (SNOMED CT®), which is used by permission of the College of American Pathologists. ©2002-2004 College of American Pathologists. All rights reserved. SNOMED CT has been created by combining SNOMED RT® and a computer based nomenclature and classification known as Clinical Terms Version 3, formerly known as the Read Codes Version 3, which was created on behalf of the U.K. Department of Health and is a Crown Copyright. SNOMED and SNOMED CT are registered trademarks of the College of American Pathologists.

EpicCare Link® Epic Spring 2008 Release © Copyright 1997-2008 Epic Systems Corporation, All Rights Reserved.	U.S. Patents 5,781,891 and 5,301,105. Other U.S. Patents pending.
This product includes SNOMED Clinical Terms® (SNOMED CT®), which is used by permission of the College of American Pathologists. ©2002-2004 College of American Pathologists. All rights reserved. SNOMED CT has been created by combining SNOMED RT® and a computer based nomenclature and classification known as Clinical Terms Version 3, formerly known as the Read Codes Version 3, which was created on behalf of the U.K. Department of Health and is a Crown Copyright. SNOMED and SNOMED CT are registered trademarks of the College of American Pathologists.
MemorialCare Medical Centers are not-for-profit, community-based hospitals located in Southern California in both Los Angeles County and Orange County. Copyright © 1999 - 2009, Memorial Health Services. All rights reserved.