Nursing Home & External Facilites Registration Form



Methodist and Jennie Edmundson Hospital social workers assist patients and external facilities in order to provide patient placement.

On line access to the patient's electronic medical record will expedite the process of placement in an extended care facility, by enhancing the communication and availability of patient data between the hospitals and the external facilities. This will decrease the time spent by the facility assessing data via a fax while maintaining HIPPA compliancy.

The information below is necessary to ensure security and authorize access to patient protected information. All fields must be completed before your application for on line access may be processed.

Attached for your review is a copy of the Facility Computer Access agreement. We will obtain your signature on the Master Agreement at the time of implementation.

* All fields must be completed.

* Facility Name:
* Street Address:
* City:
* State:
* Zip Code:
* Phone Number:
* Director of Nursing:
* Email Address:
* Administrator of Facility:
* Email Address: