Children's Hospital Colorado

    Staff Entry Form

    Complete all fields. The fields marked with * are required. This secure form will be used to grant badge and electronic access to Children's Hospital Colorado. Call the Medical Affairs office at 720-777-8396 if you have any questions.

    Section 1: Identity Section

      First Name Middle Name Last Name
    Full Legal Name: *
    Previous Name:
    Preferred "Go by" Name:
     
    Staff Type: *
    Credentials/Title: *
    (Resident/Fellow: please choose credentials)
    NPI Number: *
    DEA Number:
    **Trainees who hold a full physician license in the state of Colorado, must have their own DEA number to prescribe controlled substances.**
    Medicaid Number:
    Do you have a medical license? *
    Worked/Rotated at CHCO previously? *
    Date of Birth: *
    Gender:
    Pronouns:
    Social Security Number: *
    Passport Number:

    Section 2. Personal Contact Information
    Home Address  
    Address *
     
    City, State, Zip *
     
    Phone Type Phone Number
    Home
    Business
    Pager
    Mobile *
     
    Email Source * Email Address Preferred
    Personal
    Business

    Section 3. Program/Rotation

    Home Institution Name: *
    Residents/Fellows must list your Medical School:
    CHCO Program/Rotation: *
    Program Type: *
    Are you primarily based at CHCO? *
    CHCO Rotation Start Date:
    CHCO Program Completion Date:
    Do you have EPIC experience within the last year? *