MyDCH User Requisition

This Agreement must be completed and signed by each individual (“User”) requesting access to Driscoll Children’s Hospital’s (“Driscoll”) MyDCH, an electronic portal established to enable the sharing of protected health information contained in Driscoll’s electronic medical record via a secure, web-based electronic communication system. The Agreement must be completed and approved by the Driscoll Information Technology Department before access will be granted.

MyDCH User Requisition

Phone

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Organization/Company Clinic

Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax

Authorizing Physician, if applicable

Individual Requesting Access (User)

First Name(Required)

Middle

Last Name(Required)

Email(Required)

Speciality/Job Title(Required)

Purpose/Reason access is required

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