CCHC Provider Account Request and Attestation Form Thank you for your interest in joining CCHC. In order to provision you with ‘Care Team Portal’ access to CCHC and any applicable Electronic Health Record (EHR) interfaces to/from CCHC, please complete the following steps.
Step 1: Complete the below registration form All providers added to a practice with existing CCHC interfaces to their EHR system will be set up and activated for all interfaces.
Registration Form: Provider Full Legal Name
Provider Specialty
Provider DOB
Provider Gender
Medical License Number
License State
License Type
NPI Number
DEA Number
Practice Name
Email Address
Mail Address
City, State, Zip Code
Phone Number
Fax Number
Page 1 of 2 Step 2: Ensure that your practice has already signed the CCHC Provider Participation Agreement
If this request form is submitted to CCHC without an existing provider participation agreement, this request will not be processed.
Step 3: Sign and complete the CCHC Provider Participation Agreement Attestation
Provider Agreement Attestation
I, ______(printed name), hereby attest that I am a provider with ______(practice name).
I further attest that my signature below signifies my agreement to be bound by and comply with all the terms of the Health information Exchange Provider Participation Agreement, the Terms and Conditions for Health Information Exchange Organization Provider Participation Agreement, and Central Coast Health Connect Security & Privacy Policy and Procedure Manual.
Signature: ______
Date: ______
Step 4: Print then Sign, Scan and Email
Please print, then sign, scan and email this request form to: [email protected]
Once received and processed, CCHC staff will provision your account with access to the specific practice you requested and will provide you with a username and temporary password for the CCHC “Care Team Portal.” If your practice has an existing EHR interface, any applicable interfaces will be configured and you will be contacted to validate activation.
Please contact the CCHC Help Desk at 831-644-7494 with any questions.
Thank you, CCHC Help Desk
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