accessCHOA

New Practice Request Form

Please fill in all fields. (All required data must be entered before submitting your request. You may submit a request for additional users, as needed.).
 
Practice Group Name (Please enter as listed on your tax identification number)
 
Site Administrator

Tax ID#
 
Address Line (Primary Mailing Address)
 
City
 
State
   
Zip Code
   
Office Phone (Primary/Appointment Number)
   
Office Fax

Practice Website

CHOA Employee Assisting You

Please enter below all Practitioners and/or Other Professionals in your Practice Group who you would like to request permission to accessCHOA. PLEASE NOTE: A minimum of one practitioner who is a MD, DO, DDS, DMD, DPM, DC, OD or Psychologist, and one site administrator (if different than the practitioner). Please remember to include any physicians for whom you would like to see patient information.

First Name Legal Name - No Nicknames or Abbreviated NamesMiddle InitalLast Name Legal Name - No Nicknames or Abbreviated NamesLast 4-Digits of Your SS#Job Title Examples: MD, NP, RN, Biller, Off MgrEmail AddressContact PhoneProfessional License# & StateSite Administrator 
Click on "NEW" to start. Edit  Delete
              New    


Page 1 of 2
Content

Issue with the page?

Contact the Service Center at: (404)785-6767.

Email Us!