Health Care Provider or Business Request Form for Access to Virtua Health Patient Electronic Health Information (EHI)

Please complete the following form if you are a health care provider/site or other business requesting access to Virtua Health (Virtua) patient electronic health information (EHI) via Virtua’s Physician Link (also known as Epic Care Link) portal or other electronic means, such as an HL7 feed, an interface, or a third party application. Someone from Virtua will contact you in the near future to follow up on your request.

If you are a Virtua patient, a legal representative of a Virtua patient, health care provider or other individual authorized to act on behalf of a patient, who would like to request copies of your/the patient’s medical records, please do not complete this form. Instead, please visit this page for information on how to submit such request.

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Are you a Health Care Provider or Facility?
Please select one

Primary Contact Information

Please enter first name

Please enter last name

Please enter job title

Please enter a valid phone

Please enter a valid e-mail

Please enter facility name

Please enter facility address

Please enter facility city

Please Select State
Please enter a valid zip code

Site Information

Please enter site name

Please enter a valid phone

Please enter site address

Please enter site city

Please Select State

Please enter a valid zip code

Site Type
Please select one option
Type of User(s) at site:
Please select one option

Please enter non clinical role

Does anyone at the site already have a Virtua Physician Link account?
Please select one option
Are any of the site’s health care providers a member of Virtua Health’s medical staff?
Please select one option

Please enter name(s) of providers

Does the site use an Electronic Medical Record System (EMR)?
Please select one option

Please enter EMR name

Type of EHI Requested

What type of EHI is being requested?

Please enter first name

Please enter last name

Please enter a valid birthdate (mm/dd/yyyy)

Please enter patient address

Please enter city

Please enter a valid zip code

Please explain reason for request

Please describe the EHI requesting

Proposed Data Format (select one):
Please select one option

Please enter data format

Please describe site/business' relation to patient

Do you have a valid HIPAA authorization from the patient to access his or her EHI?
Please select one option

Please explain

Please describe the popultion of cohort

Please explain reason for request

Please describe the EHI requesting

Proposed Data Format (select one):
Please select one option

Please enter data format

Please describe site/business' relation to patient

Do you have valid HIPAA authorizations from the cohort of patients to access their EHI?
Please select one option

Please explain