ChartMaxx Request for Access

Use the form below to request access to ChartMaxx. After populating all required fields, press the Submit Request button. Once your training has been verified and your Department Director approves, you will be contacted with your sign-on ID and password for ChartMaxx within 48 business hours. If you have questions or problems, call the Customer Support Desk at 638-6568.

* denotes a required field.

Your Information
*First Name:
Middle Initial:
*Last Name:
*Email Address (john.doe@chsys.org):
*Phone (123-456-7890):
Network/Email Username:
*Children's Universtiy ID (CHS123456):

Job Information & Duties
*Supervisor Name:
*Supervisor Email (john.doe@chsys.org):
*Supervisor Phone (123-456-7890):
*Department:
	I'm not a CHS Employee

*Job Duties (check all that apply)
Access/Scheduling Staff (Access manager approval required)	Access Center Use Only
Ancillary Staff (all other clinical except nursing and physician)	Access Management (Access director approval required)
Internal Auditor/Medical Review (IA or IC director approval required)	Medical Record Use Only
Business Office (RC director approval required)	MIS Coding (MR director approval required)
CBH (CBH director approval required)	MIS Department (MR director approval required)
CHIPS	MIS Document Manager (MR director approval required)
Physician Office Staff	MIS Management (MR director approval required)
Nursing	Release of Information (MR director approval required)
Patient Relations (PR director approval required)	Information Systems Use Only
Performance Improvement (PI director approval required)	IT Department (IT director approval required)
Quality Utilization Management (PI director approval required)
Risk Management (PI director approval required)
Unit Secretary