Note:

Larger organizations wishing to create multiple entities, each having its own contact person, should submit one form for each separate entity. See New Entity Data Collection Form for further discussion of this option.

Purpose:

This form is submitted to MHA to request the establishment of a facility in CAHS. Once submitted, please complete the "User Request Form".

Directions:

• Option 1: Complete form on-line and <Submit>.
• Option 2: Download the form in Microsoft Word, complete it, save it, and then attach to an email to CAHS@mhaonline.org
• Option 3: Print out this form, complete it, and then:
  • Submit via fax to 410-379-8239
  • Send via US Mail to MHA, 6820 Deerpath Road, Elkridge, MD 21075

Name of facility/entity:   

County in Maryland:      

This request is being made by the facility/entity contact person. The facility/entity contact person is aware that:

• they are responsible for ensuring confidentiality of the system is maintained by any users of CAHS at this entity,
• they are aware that data entered about this entity can be viewed by other users of CAHS, and
• they are requesting the above entity be entered into CAHS and users be given access to the system.

The facility/entity contact person with the MHA for the above entity will be:

Name:  

Title:     

Phone:  

REQUIRED E-Mail Address:        
(If you do not include a valid e-mail address, your information will not go through —
even if it seems like it has. The e-mail address will be used only for purposes of
submitting this form; it will not be shared with or given to other people or organizations.)