DHMSO Portal Access Request

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.

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.

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.

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.

Prefer the original? Download the blank PDF Back to CHS MSO registration

Group information

Company legal name *

Federal Tax ID / TIN (nine digits) *

Business name (if different)

Does this group include PCPs, specialists, or both?

PCP(s) Specialist(s) PCP(s) and Specialist(s)

What kind of request is this?

Please choose one.

Add IPA Dignity Health Medical Network Central CA: DHMNCCA. New user access Each network chosen requires the user to have a different user id/login, but there can be multiple TINs for the same network. Add / change access View or submit authorizations, or view claims. All accounts have eligibility access. Account reactivation Reactivate a disabled or locked account. Password reset

Add a Tax Identification Number Delete a Tax Identification Number

Which portal(s) are you requesting?

Please choose at least one. Each opens its own section below.

DHMSO Provider Portal (EZ-NET) The current portal. Data from 5/1/2025 onwards. The paper form calls this one “EZNet”. DHMSO Provider Portal (Legacy) The older portal, kept for historical data from 4/30/2025 and prior, plus memos.

Who needs access?

Everyone listed here receives the same access chosen above. If different representatives or staff need different access, please complete a separate form for each group.

Each user needs their own work email that identifies them. Generic mailboxes such as office@ or billing@ will not be accepted, and shared emails are not permitted.

Working from a list? Copy your staff or representatives and paste into any cell below: a spreadsheet selection, or one person per line such as Doe, Jane <jane@practice.com> (661) 555-0123.

Row	Last, First *	Work email *	Work # *	Cell / alt #	Remove

Authorization

Requests not submitted by an Authorized Representative, or without the required information, will not be processed.

* I am an Authorized Representative of this group and the information above is accurate and complete.

Saved draft

Your answers are saved in this browser as you type.

Trouble with this page? Email or call .
Questions about the request itself should go to the helpdesk at .

Finish these items first:

DHMSO Portal (Legacy and/or EZ-NET) Access Request for QualCare IPA

Complete the DHMSO Portal form online

Group information

Does this group include PCPs, specialists, or both?

What kind of request is this?

Which portal(s) are you requesting?

DHMSO Provider Portal (EZ-NET) request

What should these users be able to do? *

Networks *

DHMSO Provider Portal (Legacy) request

Role *

Networks *

Who needs access?

Authorization

Saved draft

This is what will be saved