Post-Acute Care Facility

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
Facility Manager/Director
Administrator/CHOA Sponsor
First Name

Last Name

Service Type

Job Title
Office Phone#
Office Fax#

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.

Please note: accessCHOA’s site administrator is the person who regularly accesses the system and who will be doing site verification every 6 months. To avoid users being locked out of the system, site verification must be done every 6 months.

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 PhoneaccessCHOA’s Site Administrator 
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