Deactivate User Account - EpicCare
Name of Facility
*
User Legal Name
*
Legal First Name
Legal Last Name
Previously used login ID
User Role
*
Provider
Clinical Staff
Front Desk/Administration
User Email
*
example@example.com
Reason for Deactivation?
*
If deactivation of EpicCare Link Provider, will orders continue to be placed within EpicCare Link on behalf of this provider?
*
Yes
No
Sponsor Legal Name
*
Legal First Name
Legal Last Name
Sponsor Contact Number
*
-
Area Code
Phone Number
Sponsor Email
*
example@example.com
Submit
Should be Empty: