MyDCH User Requisition | Driscoll Children’s Hospital

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.

Fields marked with a * are required

Organization/Company Clinic

Name

Adress

Phone

Fax

Authorizing Physician, if applicable

Individual Requesting Access (User)

First Name

Middle

Last Name

Email

Specialty/Job Title

Purpose/Reason access is required

Please read our terms of this Agreement.

By Checking this box, I agree that it may serve as my electronic signature and that I have read the terms of this Agreement and agree to abide them.