• Add or Remove User Form

    CHR & eReferrals

  • Directions:

    Please complete this form to notify the Reliance eHealth Collaborative of user(s) who are joining or leaving the practice. Reliance staff will contact you when the change has been completed. For additional questions please email helpdesk@reliancehie.org.

  • Requestor Details

    Change requests must be submitted by your authorized Reliance account administrator.
    • User Role Descriptions 

    • The Access to portal(s) is role based the level of access for your user(s) is determined by your selection(s). Please see details below:

      CHR Roles:

      Staff Basic - Clinic Staff will have access to only demographic information.

      Staff Clinical - Clinic staff will have access to clinical & demographic information.

      eReferral Roles:

      Referral Manager - Access to send/update & process inbound eReferrals. Access to referral reporting.

      Referral User - Full access to send/update, & process inbound eReferrals.

      Read Only - No editing capability.

    • Add User(s) 
    • Add  
    • Remove User(s)  
    • Remove  
    • End 
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    • Should be Empty: