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NEW ROI ACCOUNT REQUEST FORM
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.)
 
First
Last
Phone
Email
Job Title		 Read
EULA
1) - -
2) - -
3) - -
4) - -
5) - -
 
Protected Health Information Access and Use Agreement
Click to read PHI agreement

In order to comply with state and federal privacy regulations, entities seeking access to MemorialCare Link must read and agree to the Protected Health Information (PHI) Access and Use Agreement.

By completing the form below and clicking the "Agree, Sign & Submit" button below, you will submit your request for a
New Non-Provider Office Account and agree to the terms outlined in the MemorialCare Health System
Protected Health Information Access and Use Agreement.

First Name: Title:
Last Name:
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.