Practice Portal Enrollment Request
Practice Portal Enrollment Request
Name
Name
*
Title
First
Middle
Last
Suffix
Role Requested
*
All Reports
AH Reports Only (CM & Claims)
AHSCA Reports Only
AH Care Management Reports Only
AH Claims Reports Only
None
Email
*
Phone
Phone
*
-
###
-
###
####
Practice Name
*
Notes/Special Instructions