EpicCare Link - Access Request

Image

Access request for Titus Regional Medical Center (TRMC) EpicCare Link for authorized staff and providers.  It is the responsibility of the requestor to provide notification of termination immediately to TRMC to allow for removal of access to Hospital Information Systems.

Signed agreements are necessary for access to Titus EpicCare Link.  Please fill and submit the form below.  After submission you will be directed to a download link to our User Agreement.  Print the User Agreement, complete the required items, scan and email it back our Provider Connect email at EMR.Support@TitusRegional.com.

DOWNLOAD USER AGREEMENT HERE

Provider Information

Provider Type*:
ProviderClinical StaffNon-Clinical Staff
Name (First MI Last):
Date Of Birth*:
Phone Number*:
Fax Number*:
Email*:
Degree*:
Specialty*:
Medical License Number*:
Medical License Expire*:
Authorizing Provider*:
Authorizing Provider NPI*:

Organization Information

Organization Name*:
DBA (Doing Business As):
Organization Type*:
Phone Number*:
Fax Number*:
Mailing Address*:
Mailing Address 2:
City*:
Organization NPI*:
State*:
Zip Code*:
Please explain your business need: