Physician/Designee Portal Registration

Please select the best description of your relationship with Children's Medical Center Dallas:I am a physician who refers patients and views clinical information. I am a nurse practitioner or PA that works for an office or medical group that refers patients and need to view clinical information. I am a physician who does not require access to clinical information. I am a registered nurse or non-clinical portal designee that needs to view clinical information
Please check this box if other Physicians in your practice require access to your patients' clinical information.

Personal Information
First Name*	MI Last Name* Degree*
Gender*	MaleFemale
State of License		State License #*
License Expiration Date		NPI #
Primary Specialty		Secondary specialty

Contact Information
Office Name*		Office Phone*
Office Address 1*		Office Fax
Office Address 2		After Hour Phone
Office City*		Office Email*
Office State*
Office Zip*

Physician Designees Information
You may now designate personnel from your office to have view-only access to your patient list via the Children's Portal. To designate access to Children's Portal, complete the form by clicking the link to the right for your user(s). Re-authorization will be requested in 180 days to ensure your user(s) require access. Children’s will initiate re-authorization.		Please Click here to Download Form to list your Designees.

Portal User Name and Password
Please allow us five business days to verify your credentials and set up your account. We will email your user name and password as soon as your credentials have been verified. As a security measure, would you select a security question from the list below and provide us your answer.
If you forget your password, we will ask you this question:*

Provide your Answer:*

Terms and Conditions*	Do you agree with the terms and conditions?	YesNo
		Indicates required field: *