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PROVIDER CONNECTIVITY REQUEST FORM

In order to connect to MHP's CMHC system, users must be registered with MHP.  Once registered, users will be assigned usernames and passwords to access Citrix and/or the CMHC system.

To register, complete the form below, then click the 'Submit' button.  After processing the information, the user's information will be sent via encrypted email to the organizational contact.

If you have questions, please send an email to MH_CMHC_HELP@ mentalhealthpartners.org

(Providers can also retrieve employee usernames by using this link and logging into the system.  Account creation usually takes ~5 business days to complete)

* indicates required data
 
Provider Information
* Provider Name:  
   
User Information
* First Name:  
Middle Initial:
* Last Name:
   
* Email:
* Telephone:
  format: 333-333-1234
Connectivity Information
* Connectivity Type:
* PC Serial Number:
* Antivirus Installed?
   
* Connectivity Requested?  Claims Entry
   Auto-Auths
 
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