Hale | Provider EHR Mapping Request
Use this form to request configuration of any new clinical team member that requires mapping to the EHR in order to support integrated functionality. Note that users must have activated an account before mapping can be finalized. For any questions, reach out to support@hale.co
Sign in to Google to save your progress. Learn more
Hale Team Name *
Name of Authorized Representative [Submitter] *
Email of Authorized Representative [Submitter] *
Provider User Name *
Provider User Email Address *
EHR Provider ID *
User ID or abbreviation used in the integrated system. If unknown, please indicate any other identifying information to assist in correct mapping.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Hale Health. Report Abuse