<p> 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.</p><p>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. </p><p>Registration Form: Provider Full Legal Name</p><p>Provider Specialty</p><p>Provider DOB</p><p>Provider Gender</p><p>Medical License Number</p><p>License State</p><p>License Type</p><p>NPI Number</p><p>DEA Number</p><p>Practice Name</p><p>Email Address</p><p>Mail Address</p><p>City, State, Zip Code</p><p>Phone Number</p><p>Fax Number</p><p>Page 1 of 2 Step 2: Ensure that your practice has already signed the CCHC Provider Participation Agreement</p><p>If this request form is submitted to CCHC without an existing provider participation agreement, this request will not be processed. </p><p>Step 3: Sign and complete the CCHC Provider Participation Agreement Attestation </p><p>Provider Agreement Attestation</p><p>I, ______(printed name), hereby attest that I am a provider with ______(practice name). </p><p>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. </p><p>Signature: ______</p><p>Date: ______</p><p>Step 4: Print then Sign, Scan and Email </p><p>Please print, then sign, scan and email this request form to: [email protected] </p><p>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.</p><p>Please contact the CCHC Help Desk at 831-644-7494 with any questions. </p><p>Thank you, CCHC Help Desk</p><p>Page 2 of 2</p>