For You / Health Care Professionals / Deaconess Care Link / CareLink Access Request Form

CareLink Access Request Form

This request for access must be completed by the practice manager.
Any account not used within 180 days will be disabled.
For login or password issues, please call 812-450-4357, Option 9
For other Care Link questions call 812-450-9003 or email carelink@deaconess.com

Once you have filled in the required fields, click on the "Submit" button at the bottom of the form. The Deaconess Business Development Group and Information Technology Teams will process your request and provide the new user IDs/passwords to the site admin who submitted the request once the accounts have been created. We may also need to contact the requestor by phone or e-mail to verify the request was submitted by an appropriate manager, or to validate any details provided in the request. User access requests generally take between 3-5 business days to fully complete.

Your Facility/Site Info

Primary Organization You Will Be Accessing:

Your Facility Type:

Please describe facility type:

Facility Name:

Facility NPI:

Facility Street Address:

Facility City:

FacilityState:

Facility Zip:

Facility Primary Phone:

Facility Primary Website Address:

CareLink Site Administrator Info

Site Admin First Name:

Site Admin Last Name:

Site Admin Title:

Site Admin Last 4 SSN:

Site Admin Direct Phone:

Site Admin Direct Email:

CareLink User Info

Number of Users to Add/Change:

User Request 1

Type of Request:

First Name:

Last Name:

last 4 SSN:

Access Type:

Does user need access to SECTRA/PACS for viewing imaging studies:

User Request 2

Type of Request:

First Name:

Last Name:

last 4 SSN:

Access Type:

Does user need access to SECTRA/PACS for viewing imaging studies:

User Request 3

Type of Request:

First Name:

Last Name:

last 4 SSN:

Access Type:

Does user need access to SECTRA/PACS for viewing imaging studies:

User Request 4

Type of Request:

First Name:

Last Name:

last 4 SSN:

Access Type:

Does user need access to SECTRA/PACS for viewing imaging studies:

User Request 5

Type of Request:

First Name:

Last Name:

last 4 SSN:

Access Type:

Does user need access to SECTRA/PACS for viewing imaging studies:

Provider Info

This section is not for requesting CareLink user accounts. In this section, please list Providers at your facility who have a direct relationship such as PCP or Referring physician to mutual patients. When these providers are linked to your CareLink facility record and are also linked to a patient encounter in Deaconess' EHR, the patient record will automatically populate into your Deaconess CareLink Patient List.

Number of Providers to Add/Change:

Provider Request 1

Request Type:

First Name:

Last Name:

NPI:

Provider Request 2

Request Type:

First Name:

Last Name:

NPI:

Provider Request 3

Request Type:

First Name:

Last Name:

NPI:

Provider Request 4

Request Type:

First Name:

Last Name:

NPI:

Provider Request 5

Request Type:

First Name:

Last Name:

NPI:

Additional Comments

Additional Comments:

Show Terms of Use Agreement

PRACTICE TERMS OF USE AGREEMENT

As a condition of access to the network and patient record systems of Deaconess Health System ("Deaconess"), the undersigned agrees on behalf of practice names listed below to the following Terms of Use.

Access to the network and electronic patient record systems of Deaconess is a privilege and not a right of association with Deaconess, and may be terminated at any time and for any reason.
Access to the network and patient record systems of Deaconess is provided to external providers and members of their staff solely for the business needs of the provider and subject to all applicable federal and state laws.
Access to patient records maintained by Deaconess is permitted only for those patients with whom the Practice has a professional relationship as the private, attending, admitting, referring, consulting or on-call provider.
The Practice will identify those individuals within Practice who require access to the Deaconess network or patient record systems in order to perform their essential job functions, and will assure that all such individuals identified have read and signed the End User Terms of Use Agreement
Each authorized user will be issued a unique user ID and password which may only be used by the person to whom it is assigned.
The Practice will notify the Deaconess Information Systems HelpDesk within 7 days if an individual's change in, or termination of, job responsibilities requires modification to his/her user privileges.
The Practice will promptly notify the Deaconess Privacy Officer or Information Security Officer of any alleged or known unauthorized use of the Deaconess network or patient record systems by any person.
All persons associated with Practice will cooperate in any investigation conducted by Deaconess involving an alleged or known unauthorized acquisition, use or disclosure of information from Deaconess patient records.
The Practice is responsible for developing its own policies and monitoring program regarding privacy and security of information, for educating its staff on these policies, and for taking corrective action when its policies are violated.
End-user violations of the End User Terms of Use Agreement may result in corrective action by Deaconess up to and including termination of user privileges.
Violations of this Practice Terms of Use Agreement may result in suspension of all user accounts assigned to Practice.
Breaches of the protected health information or personal information of Deaconess patients will be reported in accordance with applicable statutes to the person(s) whose information was breached and, as appropriate, to state or federal authorities.
This Practice Terms of Use Agreement will take effect on the date it is signed by Practice.

By checking the "I agree" box below, I certify that I have read and accept the Terms of Use Agreement and that I am authorized to make this request.

I Accept