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Surgeon Portal Registration

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    Surgeon Portal Registration

    Welcome to the registration for the Rocky Mountain Lions Eye Bank's Surgeon Portal. Access to the portal will allow your practice to schedule patients and request transplant ocular tissue directly in the eye bank's distribution calendar. 

    This form should only be filled out for the person who will act as the "practice administrator." This person will not only have access to the practice's tissue request calendar, but will also have the ability to add and delete others users withing the practice.

    By submitting this form, you agree to notify the Rocky Mountain Lions Eye Bank immediately if the admin user named below leaves the employment of the practice named below so that a new admin user may be assigned and the user de-activated from the system. 

    HIPAA disclosure: Patient information transmitted via the RMLEB Surgeon Portal is NOT protected health information under existing HIPAA law and patient permission is not required. All health information related to the donation and transplantation of organs and tissues is HIPAA exempt. 

    Name of the physician practice: 
    Address (main address if more than one location): 
    City:    State:    ZIP: 
    The following person will be set up as the account admin user. 
    First Name:   Last Name: 
    Telephone:   ext: 
    Email (required for portal access): 
    There are errors in your form, please see above for details.