Apply for Advanced Care Planning Privileges

El Camino Provider Approval Form

The identified roles and permissions identified within the Advanced Care Planning Platform are as follows:

  1. Signer (MD, DO, NP, PA): The ability to create, sign, void, complete all aspects of an Advanced Care Planning form.
    • This role typically involves: Physicians, Physician Assistants, Nurse Practitioners, etc. (participants with an active License #)
  2. Preparer (RN, Social Worker): The ability to create, but not sign/complete all aspects of an Advanced Care Planning Form.
    • This role typically involves: Registered Nurses, Social Workers, Healthcare Advocates, etc.
  3. Uploader (office admins, and signer/preparer): The ability to upload, view and void a form.
    • This role typically involves: approved administration staff working with a practice/under a licensed healthcare leader.

Please review the information below and fill out to its entirety. The information requested is required for full approval and access into the El Camino Advanced Care.

Applicants should receive approval within a 72hr window. Once approved, applicants will receive an email notification to activate their log-in.
NOTE: the activation link will expire one week from sending.

Expect log-in email to come from "".

(Name, Address, Phone and primary contact/information for Practice)
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

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