PowerChart Request Form
This access is not available to nursing or admin staff.
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Full Legal Name
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Do you have an active medical license?
Yes
No
NPI Number (required for active medical license)
Medical License Number (required for active medical license)
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Position Code
-- Select Position --
Audiologist (AuD)
Certified Registered Nurse Anesthetist (CRNA)
Clinical Genetics Counselor (GC)
Doctor of Dental Medicine (DMD)
Doctor of Dentistry/Dental Surgery (DDS)
Doctor of Medicine (MD)
Doctor of Osteopathy (DO)
Doctor of Pharmacy (PharmD)
Doctor of Philosophy (PhD)
Doctor of Psychology (PsyD)
Licensed Clinical Social Worker (LCSW)
Licensed Professional Counselor (LPC)
Neonatal Nurse Practitioner (NNP)
Nurse Practitioner-Certified (NP-C)
Physician Assistant-Certified (PA-C)
Certified Surgical Assistant (CSA)
Doctor of Podiatric Medicine (DPM)
Other
If Other, please type your position code
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Practice Name
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DOB
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Practice Address
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Provider Email Address
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Contact Number
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Alternative POC Full Name
Provide an alternative POC (ex. Office Mgr, Head Nurse, etc.) to receive CHKD documentation and processing information as well
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POC Email Address
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Contact Fax
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CHKD Physician Liaison
-- Select Liaison --
Marc Tsou,MD
Jill Armstrong,RN
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Your Practice Location
-- Select Location --
Virginia/North Carolina
Other
Sponsor Doctor at CHKD (required for Other practice location)
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Reason For Access
You must change your password every 6 months. You will need to log in periodically at least every 6 months to prevent termination of access.
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