Provider Staff Entry Form - CHCO Web Forms

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? *

Yes

Worked/Rotated at CHCO previously? *

Yes

Date of Birth: *

Gender:

Pronouns:

Social Security Number: *
(Format: ###-##-####)

Passport Number:

Section 2. Personal Contact Information

Home Address
Address *	*

City, State, Zip *	* *

Phone Type	Phone Number
Home
Business
Pager
Mobile *	* I acknowledge that my personal cell phone number will be used for CHCO business and clinical communications throughout the duration of my training program. *	*

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? *

Yes