Purpose:

This form can be used by a facility to suggest additional potential users of the CAHS system.
MHA will use the data to contact these potential clients. It is in the interest of a school to have
all their partners using CAHS in order to have all data in one place.

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

This form is being submitted by the following school contact person:

Name:  

Facility: 

Phone:  

REQUIRED E-Mail:  
(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.)

Healthcare entities we interact with who may be interested in CAHS:

Name of entity:    

Potential contact person:   

Phone number:    

Name of entity:    

Potential contact person:    

Phone number:    

Name of entity:    

Potential contact person:    

Phone number:    

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