EHC Account Request

Account Request Information

*First Name:    *Last Name:     
      *MI:      *Title/Position:     
*Work Phone:    Professional Lic#:    
*Division:     *Job Function:     
*Employed By:          Current LOGON ID:     
(if you already possess one)    

Additional Information:

 *Requestor:   *Req. Email: 

 

Download, Sign and fax the HIPAA Confidentiality form to 404-712-1322