accessCHOA

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

Address

City

State

ZipCode

Job Title

Office Phone#

Office Fax#

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.

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 Name	First Name (No Nicknames or Abbreviated Names)	M.I.	Last Name (No Nicknames or Abbreviated Names)	Job Title/Function	Last 4-Digits of SS#	Email Address	Contact Phone	accessCHOA’s Site Administrator
Click on "NEW" to start.									Edit Delete
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