UTMB CareLink

UTMB CareLink Request

Please complete the information below and click the "Submit" button. If some fields do not pertain to your organization, you may leave them blank.

Select the purpose of this request:
Practice Information
Practice Name
Office Name
Street Address Suite
City State Zip Code
Email Phone
Physician Associated with this Practice
(List additional physicians in the Additional Users section below)
First Name Last Name
Email Phone
License or Tax ID# Date of Birth MM/DD/YYYY
NPI#


Key Contacts

Site Administrator

The Site Administrator is usually the practice manager, office manager or supervisor and serves as the central point of contact for your account. They should be generally available to all staff during normal business hours and familiar with UTMB CareLink.

First Name Last Name
Email Phone
Job Title
Does user need access to UTMB CareLink?
    Yes   No


Privacy Contact
First Name Last Name
Email Phone
Job Title
Does user need access to UTMB CareLink?
    Yes   No

Additional Users
(Other than physician and site administrator listed above)
First Name Last Name
Email Phone
Job Title
License  IF PHYSICIAN Date of Birth   IF PHYSICIAN
NPI#  IF PHYSICIAN


First Name

Last Name
Email Phone
Job Title
License  IF PHYSICIAN Date of Birth   IF PHYSICIAN
NPI#  IF PHYSICIAN


First Name

Last Name
Email Phone
Job Title
License  IF PHYSICIAN Date of Birth   IF PHYSICIAN
NPI#  IF PHYSICIAN


First Name

Last Name
Email Phone
Job Title
License  IF PHYSICIAN Date of Birth   IF PHYSICIAN
NPI#  IF PHYSICIAN