CareLink Form – Updated Office Information Practice Name (required) Address City State —Please choose an option—AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia Zip Phone Fax Email Group NPI Add Physicians Name NPI License # -+ Site Administrator Please note that the email provided for the site administrator will be the account that receives alerts when Cooper University Health Care uploads information for any patient of the group. First name Last name Email Phone Choose 4-digit PIN (required) Please acknowledge by checking this box that you have read and understand that, following your submission: You will receive an email confirming receipt of your CooperCare Link application. The email you provided for the site administrator above will be where all communication alerts will be sent by Cooper. You will be able to add users and additional emails by contacting privacyofficer@cooperhealth.edu. By clicking “I agree” below, I certify that (1) I am an authorized representative of the Practice with the full and complete authority to bind the Practice to the terms and conditions of the Site Access Agreement, which can be accessed at https://coopercarelink.cooperhealth.org/wp-content/uploads/2021/02/210215_ssa_agreement.pdf, and (2) on behalf of the Practice, I agree to the terms and conditions set forth in the Site Access Agreement. I agree Please leave this field empty.
