New Facility - EpicCare Form

New Facility Form
Legal Name of Facility*
Facility NPI #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Note: All site administrators must have an active EpicCare Link account. Your login ID and temporary password will be emailed to you within five business days after your facility is approved.
Site Administrator's Legal Name*

Legal First NameLegal Last Name
Site Administrator's Role*
Site Administrator's Contact Number*

Area CodePhone Number
Site Administrator's Email*
example@example.com
Alternate Legal Name for Site Administrator*

Legal First NameLegal Last Name
Alternate Contact Number for Site Administrator*

Area CodePhone Number
Alternate Email for Site Administrator*
example@example.com
Should be Empty:

New Facility Form