CMHPSM CRCT EHR Provider Login Request Form

CMHPSM CRCT Provider Login Request
This form submits to the CMHPSM and should be used by organizations contracted directly with the CMHPSM (i.e Substance Use Disorder Treatment Service Providers).

All mental health providers with CRCT login requests should visit their local CMH website or contact the local CMH directly.
Request *

New Employee Account Remove Employee(s) Account Request Access Change for Existing Login
Provider Name: *
Provider Site:
Requestor needs to be a supervisor or designated CRCT support person. The requestor needs to be different than the user/employee the request is being made for. Please contact the help desk if you need further assistance.
Requester: *

First Name Last Name
Requester Email: *
Create new CRCT employee account or edit existing CRCT account access:
Employee Name: *

First Name Last Name
Email: *
NPI Number:
Job Title: *
Phone Number:

Area Code Phone Number
Fax Number:

Area Code Phone Number
Account Access:
Access Request:

Select Module Access for User Model New User Account Access Based Upon Another Employee
Model Employee:

First Name Last Name
Module Access:

SUD Clinician SUD Clinician ASAM Continuum Module Access Incident Report Entry Accounts Payable / Encounter Data Entry
Upload .pdf or image file Copy of ASAM Continuum Training Certificate
*A training certificate is required to be uploaded to gain access to the ASAM Continuum Module
Remove the following individual(s) from CRCT on effective date:
Remove:

First Name Last Name
Effective Date:

Month Day Year
Remove:

First Name Last Name
Effective Date:

Month Day Year
Remove:

First Name Last Name
Effective Date:

Month Day Year

CMHPSM Staff Section
Process Date:

Month Day Year
Request Processed by CMHPSM:

Processed
Should be Empty:

CMHPSM CRCT Provider Login Request