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: *
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: *
CHCO Rotation Start Date:
CHCO Program Completion Date: