Children’s Health Network: Request for Application Apply for Membership into Children's Health Network (CHN) Date of Request* MM slash DD slash YYYY Requestor Information Requestor Name* First Last Requestor Phone* Requestor Email* Your email address will be your portal username. When your account is activated by our staff, you will need this to log in to the portal. Requestor Password* Please record this password in a safe place. When your account is activated by our staff, you will need this to log in to the portal. Enter Password Confirm Password Strength indicator Provider Information Provider Name* First Last Provider Title* Provider Specialty* Provider Date of Birth* MM slash DD slash YYYY Last 4 Digits of Provider's SSN* Provider Gender Male Female If you are an advanced practice clinician, please enter the name of your collaborating physician: What Are Your Board Certifications?* If not board certified, please explain. Primary Practice/Group Name* Primary Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is mailing address different from practice address?* Yes No Mailing Address (if different than primary practice address) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Office Phone* Primary Office Fax* Provider NPI Number* Provider's Primary Hospital Affiliation* Start date of new provider, if known MM slash DD slash YYYY If the start date is unknown, it is preferred that you enter an estimated date. Comments or Concerns Contact Us If you have any questions or concerns regarding the purpose of this form, or its completion, please do not hesitate to contact us at 402-955-8932 or [email protected] Please check the box below:
