Provider Portal Registration

Request provider portal access

Use this form to request portal accounts for the staff at your practice. It replaces the paper registration packet.

This form does not create accounts. Every request is reviewed by the CHS MSO Portal Support Team, who set up the accounts once the request is approved.

Already have an account? If you are unable to sign in, please request help with an existing account instead of using this form.

Who is submitting this request?

I am one of the users requesting access. You will be listed among the portal users below. I am submitting this request on behalf of the requested user(s). For example, an office manager or a billing company.

Are you the supervisor?

Yes No

How should portal email be delivered?

Portal notifications and password resets are sent by email. Please select the option that matches your office.

A separate email for each user Enter each person's email beside their name below. One shared office email All portal mail goes to a single monitored mailbox.

Who needs a portal account?

List each person who needs an account, one per row, up to 20. A first and last name is required for everyone; an email is required for each person unless you chose one shared office email in the Email setup above.

Working from a list? Copy your staff and paste into any cell below - a spreadsheet selection, or one person per line such as Jane Doe [email protected]. It will be spread across the rows.

Row	First name *	Last name *	Email *	Remove

Practice information

Group / organization name *

Tax ID (EIN, nine digits) *

Practice address *

Practice phone *

Fax *

What should these users be able to see?

Access to all providers at this practice Limit access to specific providers List the providers below.

Authorization

* I certify that I am authorized to request portal access for this practice, and that the information provided above is accurate and complete.

Saved draft

Your answers are saved in this browser as you type.

Do you also need access to the DHMSO Portal?

The DHMSO Portal is a separate system with its own form, processed by a different helpdesk. This registration does not cover it, and the DHMSO form is not sent to Centric Healthcare Services. Only if DHMSO access also applies to your practice, please complete that form as well and email it to the address shown on it.

Complete the DHMSO Portal form online Download the blank PDF instead Visit the DHMSO Portal

Need help? Email or call .

Finish these items to submit: