ConnectCare Link

Credentialed and non-credentialed office must complete this form to obtain ConnectCare Link, which is a web-based application for connecting community practices to the Bon Secours Health System. It provides users secure access to their patient information in our ConnectCare data repository.

Please be sure to sign and return the Confidentiality and Security Agreement that will appear after you click the submit button below.

First Name *
Middle Initial *
Last Name *

Work Email address if available. Otherwise, general practice Email address.

email *
Practice Name *
Please enter the credentialed/associated physician of the practice.
Practice's Street Address *
Practice City *
Practice State *
Practice Zip *
Practice's Phone *
Supervisor Name *
Supervisor Email *
Last Four Numbers of Workforce Member's Social Security Number *
Date of Birth (MM/DD/YYYY) *
Workforce Member's Home Address *
Workforce Member's Home City *
Workforce Member's Home Zip *
Workforce Member's Home Phone *

By selecting this box I confirm that I am requesting ConnectCare Link.

 Connect Care Link *

Select "Yes" below, if you are employed by an agency ouside of the Physician's Office that you provide billing for.

Third Party Biller

Security question responses should be accurate and specific to each individual requesting access.

Please select a security question from the drop down listing.

Security Question 1 *

 

Security Answer 1 *

Please select a security question from the drop down listing.

Security Question 2 *
Security Answer 2 *
* required fields

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