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.
Requester:*

First NameLast Name
Requester Email:*
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.
Request Type:*

New Employee AccountRemove Employee(s) AccountRequest Access Change for Existing Login
Provider Name:*
Provider Location(s):
CRCT Affiliate(s) access requested:

CMHPSM Contract for Monroe SUD treatment servicesCMHPSM Contract for Washtenaw SUD treatment servicesLenawee Contract for Lenawee SUD treatment servicesLivingston Contract for Livingston SUD treatment services
Account Access:
Access Request:*

No User Login Access (Select this option if the individual will be entered for service billing purposes)Select Module(s) Access for UserModel New User Account Access on another Existing CRCT user
If selecting "No User Login Access" please include the individual's NPI number and their name as associated with that NPI number. This individual will be entered in to CRCT as an affiliated provider within your organization in CRCT and you will be able to select them when entering a claim as an individual provider delivering a service from your organization. Individuals with this no user login access designation will not be able to individually login to CRCT.
Create new CRCT employee account or edit existing CRCT account access:
Employee Name:*

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

Area CodePhone Number
Fax Number:

Area CodePhone Number
Model Employee:

First NameLast Name
Module Access:

SUD ClinicianSUD Clinician ASAM Continuum Module AccessIncident Report EntryAccounts Payable / Encounter Data Entry
Upload .pdf or image file Copy of ASAM Continuum Training Certificate

Browse Files
*A training certificate is required to be uploaded to gain access to the ASAM Continuum Module Cancelof
Remove the following individual(s) from CRCT on effective date:
Remove:

First NameLast Name
Effective Date:

MonthDayYear
Remove:

First NameLast Name
Effective Date:

MonthDayYear
Remove:

First NameLast Name
Effective Date:

MonthDayYear

CMHPSM Staff Section
Process Date:

MonthDayYear
Request Processed by CMHPSM:

Processed
Should be Empty:

CMHPSM CRCT Provider Login Request