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

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Group Name

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Administrator/CHOA Sponsor

First Name

Last Name

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Address

City

State

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ZipCode

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Job Title

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Office Phone#

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Office Fax#

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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 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
Click on "NEW" to start.								Edit Delete
*	*		*	*	*	*	*	New

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