Epic Provider Access and Training 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, by the Practice Manager to avoid service delays.

Note: Please allow 5 business days to complete your request. Complete the form and click Submit.

To request access to Epic, complete the following items:

Authorized Requestor's Name: *

Authorized Requestor's E-mail Address: *

Authorized Requestor's phone number: *

Authorized Requestor's Title: *

Name of Practice:

Effective Date of Privileges: *

Type of Access Request *

If you are submitting an access request for a new hire, please click here to print a copy of the PAG Confidentiality and Network Access Agreement.

Attach completed Confidentiality & Network Access Agreement:

Staff Role/Job Responsibilities (indicate if the user's access should mirror another user; provide that user's name and UH Access ID): *

Type of Request: *

New Provider (not in an Epic practice)

New Provider (in an Epic practice)

New Referring Provider

Update Provider Record (Role, Transfer, Departure)

Is this provider a resident? *

What type of resident (surgical, OB/GYN, etc.)?

Who will this resident be working with?

Is this provider employed by Piedmont Augusta? *

Will the provider be listed to receive MyChart patient messages?

Will this provider prescribe controlled substances medications? *

Will the provider be listed to receive MyChart clinical updates?

Will the provider be included in the recipient list for Appointment Request?

Will the provider allow patients to directly schedule from MyChart?

Will this provider be reading and/or performing studies for PAG Radiology departments?

Is this provider participating or planning to participate in Meaningful Use? *

Provider's First Name: (as it appears on Medical License) *

Provider's Last Name: (as it appears on Medical License) *

Provider's Middle Name: (as it appears on Medical License)

Provider's Preferred Name: (First Last) *

PAG Access ID, if known (D-ID or X-ID):

PAG Home Department (if applicable):

Access to Other Departments?: *

Other Departments:

PAG Home Dept Address 1: *

PAG Home Dept Address 2:

City: *

State: *

Zip: *

Phone: *

Fax: *

EHR Direct Address (if not Epic Ambulatory):

PAG Home Dept Secondary Address 1:

PAG Home Dept Secondary Address 2:

Secondary City:

Secondary State:

Secondary Zip:

Secondary Phone:

Secondary Fax:

Secondary EHR Direct Address:

Clinical Title: *

License for Display: *

Primary Specialty

Additional Specialties:

Provider Type *

DEA Number: *

NPI Number: *

Communication Preference:

If this provider is a cardiologist, are they registered to prescribe Tikosyn?

Will this provider round on patients at Piedmont Augusta (to include Summerville)? *

Will this provider round on patients at Piedmont McDuffie? *

Will this provider log into Epic Hyperspace at Piedmont Augusta (to include Summerville)? *

Will this provider be credentialed by the Piedmont Augusta Medical Staff Office? * 🛈

Will this provider be credentialed by the Piedmont McDuffie Medical Staff Office? *

Will this provider be performing surgeries at Piedmont Augusta (to include Summerville)? *

Will this provider be performing surgeries at Piedmont McDuffie? *

Will this provider be performing procedures at Piedmont Augusta (to include Summerville)? *

Will this provider be performing procedures at Piedmont McDuffie? *

If this provider is a surgeon, what is their glove size?

Will this provider be performing/assisting in the following procedures?

Radiology

Cath Lab

EP Lab

Should the provider be a reading physician in Merge Cardio? *

Will this provider need to see images in:

Radiology

Cardiology

Will the Provider be in an Ambulatory practice? *

Ambulatory - List all of the departments the provider will need to ONLY login to (i.e., not have patients scheduled for a visit):

Ambulatory - List all of the departments the provider will need to have a schedule for an office visit:

Ambulatory - Has the provider previously e-prescribed?

If yes, provide Surescripts Provider ID:

Ambulatory - Provide starting date for scheduling patients:

Ambulatory - Will the provider be participating in Open Scheduling?

Will the provider use Professional Billing? *

If yes, Provider Taxonomy Code:

If yes, Provider Medicare Number (if available):

If yes, Provider Medicaid Number (if available):

For what departments will the provider be listed for billing and service?

If the provider is a PA or NP, will they bill payors other than Medicare or Medicaid?

If yes, please list:

Is this an Emergency Department provider (to include Summerville)? *

Comments (please provide any additional information that may be needed to complete your request):