CHR Enrollment Form
Community Health Record Portal
Organization
Practice, hospital or other health care organization enrolling with Reliance.
Practice Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
Main Phone Number
*
Practice Specialty
Practice NPI
*
EHR Vendor
*
If no EHR, indicate 'Paper Charts'
Do you provide substance use treatment?
*
Yes
No
Company Logo (Optional)
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Office Contacts
Authorized to add/remove users. (Example: trainers, site coordinators, area supervisors, or a backup contact to the primary contact.)
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Job Title
*
Add additional office contacts?
*
Yes
No
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Job Title
*
Add additional office contacts?
*
Yes
No
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Job Title
*
Add additional office contacts?
*
Yes
No
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Job Title
*
Provider(s) Information
Practice health care provider(s). Must enter a minimum of one provider.
Enter Provider Details
*
User(s) Information
User Roles Description: Staff Basic - Clinic Staff that will have access to only demographic information. Staff Clinical - Clinic staff that will have access to clinical & demographic information.
Enter User Details
*
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