accessCHOA

Non-Physician Partner

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.).
You must assign a CHOA Operational Sponsor designee who can request access to accessCHOA for appropriate users. This person will also be responsible for coordination access for patient charts on behalf of the Sponsoring Manager/Director
 
Group Name
 
Administrator/CHOA Sponsor
 
First Name

MI
 
Last Name
 
Job Title
 
Contact Phone#
 
Purpose/Justification

Please enter the following table information for all users who you would like to request permission to accessCHOA to view limited real-time patient information.

Company/Organizational NameFirst Name (No Nicknames or Abbreviated Names)M.I.Last Name (No Nicknames or Abbreviated Names)Job Title/FunctionLast 4-Digits of SS#Email AddressContact Phone 
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