Epic Provider Departure Notification Form

All requests for user access, terminations and provider records should be submitted to the Helpdesk by an Authorized Requestor.  Practice Managers are Authorized Requestors.  Anyone else designated to be an Authorized Requestor must be identified in advance, through the Helpdesk (helpdesk@uh.org), by the Practice Manager to avoid service delays.
 
Note:  We require this form be submitted 45 days prior to departure, but no later than 30 days prior.  Please allow 5 business days to complete your request.  Complete the form and click Submit.
Will the provider still be an Admitting and/or Attending physician at University Hospital Main, University Hospital McDuffie, and/or University Hospital Summerville? *
Does the provider have any of the following functionalities set up? *

Recommended Task List for Practice Managers

  1. Update patient PCP information in Epic if provider will no longer be practicing as a PCP in the area.
  2. Update owner of any shared Patient Lists under Inpatient application prior to inactivation of provider.
  3. Update patient Care Teams.
  4. Request Meaningful Use reports.
  5. Reschedule provider’s patients.
  6. Delete provider scheduling templates.
  7. Send notification to the provider’s patients.
  8. Update on call schedules for office, Amtelco/MiSecure, etc.
  9. Inform any hospital departments, clinics, and practices that the provider worked with regularly.
  10. Close all charts and encounters.
  11. Order updated letterhead, prescription pads, patient reminder cards, etc. if applicable.
  12. Notify University Hospital Corporate Communications and Medical Staff Office of provider departure.
  13. For UMG/UCA providers, update provider's phone extension assignment.
By checking box below, I acknowledge that I have read the preceding Recommended Task List for Practice Managers. *