Complete the DHMSO Portal form online
This is the DHMSO Portal (Legacy and/or EZ-NET) Access Request for QualCare IPA: the same paper form, completed on screen instead of by hand. Everything you enter stays on this computer. Once the page has loaded it works with no internet connection, nothing is sent anywhere, and no one can see your responses until you email the PDF yourself.
Portal sign-in pages, once access has been granted:
Completing this form
After the questions below have been
answered, select Save as PDF at the foot of the page.
The
responses are formatted as the completed request form and saved as a PDF
document.
No information is submitted from this page.
Sending the completed form
Please email the saved PDF document to
.
That address belongs to the CommonSpirit helpdesk, which processes these
requests.
Centric Healthcare Services MSO does not receive a copy.
⚠ Send your email to this exact address:
⚠ With this exact subject line:
Paste them into the To and Subject
boxes of your email.
Requests sent anywhere else, or without this subject, may be delayed
or not processed.
Prefer the original? Download the blank PDF Back to CHS MSO registration