Children's Health Home Health Commerce System Account Application

• Application also available in Word Format (DOCX)

1. Director Account Health Commerce System Application

2. Organization type	Children´s Health Home CMA
3. Legal Organization name
4. Full first name (DO NOT use nicknames), full middle name (not just the initial), and full last name. (For example: Elizabeth Ann Doe)
5. Month and day of birth
6. NYSDOH Health Commerce System (HCS) ID (if one exists)
7. Job title (needed for Director requests)
8. Work address
9. Office telephone number
10. Office fax number
11. E–mail address
12. Existing Director being replaced (if applicable)
If the Coordinator is replacing someone, does the Coordinator being replaced need to retain an account as a user for the organization?
13. Date

1. Health Commerce System Coordinator Account Application

1. Organization type	Children´s Health Home CMA
2. Legal Organization name
3. Full first name (DO NOT use nicknames), full middle name (not just the initial), and full last name. (For example: Elizabeth Ann Doe)
4. Month and day of birth
5. NYSDOH Health Commerce System (HCS) ID (if one exists)
6. Work address
7. Director´s name (needed for Coordinator requests)
8. Office telephone number
9. Office fax number
10. E–mail address
11. Existing Coordinator being replaced (if applicable)

2. Health Commerce System Coordinator Account Application

1. Organization type	Children´s Health Home CMA
2. Legal Organization name
3. Full first name (DO NOT use to expedit nicknames), full middle name (not just the initial), and full last name. (For example: Elizabeth Ann Doe)
4. Month and day of birth
5. NYSDOH Health Commerce System (HCS) ID (if one exists)
6. Work address
7. Director´s name (needed for Coordinator requests)
8. Office telephone number
9. Office fax number
10. E–mail address
11. Existing Coordinator being replaced (if applicable)