LCMC Health test out form

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This form is to attest that you have prior (within the past one year) Epic EMR experience and are proficient in each of the areas / job roles you will be performing at LCMC. If you have prior experience, you will have the option to “Test Out” of training classes. Complete all questions on the form below. It is particularly important for Physicians/NPs/PAs to complete the Physician questions.

Please complete this form as early as you can so that there is time to process the request before your start date.

Name; this should be your legal first and last name, no nicknames please.*

First Name

Last Name

Date of birth (MM/DD/YYYY)*

NPI or Employee number

Contact phone number*

Work email*

Primary hospital/clinic location*

Secondary hospital/clinic location location; mandatory if applicable

Specialty/job title*

Department/manager name

Original hire date/start date (MM/DD/YYYY)*

Contract/vendor company name; mandatory if applicable

School affiliation, mandatory if applicable

For Physicians please respond to ALL of the following 4 questions. If you are not a Physician you can skip this section and go straight to the attestation.

I am an employed LCMC Health Provider (on the payroll of a LCMC Health facility)

Yes No

Patients will be scheduled to me at a LCMC Health clinic/ambulatory center.

Yes No

I will admit, transfer, and discharge inpatients from a LCMC Health hospital.

Yes No

I will be performing surgeries or other invasive procedures at a LCMC Health hospital.*

Yes No

Attestation

Per the LCMC EPIC Training Policy, end users with prior EPIC experience will be required to successfully pass a “test out”. Please remember that even if you have tested out of training, you will still be expected to attend readiness activities and/or personalization activities that are appropriate for your role, as these will reinforce key concepts and LCMC-specifics to ensure that you are prepared for go live day and beyond. An end user who does not pass the assessment will have to complete the standard Training Track for their user role. Please attest that you have prior EPIC experience (Note: student EPIC training does not qualify); by answering the following 3 questions and then submit your request for the EPIC Experienced Competency Assessment*

Yes No

The last date I used EPIC*

Facility that I used EPIC*

Frequency of EPIC use*