CalREDIE Provider Portal User Account Authorization Form

Note: Providers located in Los Angeles or San Diego jurisdictions are NOT eligible to use the CalREDIE Provider Portal. Providers located in Los Angeles or San Diego counties must contact their local health department for instructions on how to report.

A Provider Portal User is any individual authorized by a Local Health Department Liaison to use the CalREDIE Provider Portal to electronically submit reports of communicable disease to the local health department. Please fill out the form below and click Submit. Your account request will then be routed to your LHD liaison for approval.

* = Required Field

Action

Account Action

Local Health Jurisdiction

Provider Portal User Registration Information

First Name

Last Name

Credentials

Facility Name

Facility Street Address

City

State

Zip Code

User's Direct Work Phone Number

Extension

User's Work E-Mail

Email Address Type

User Signature

User Signature Date

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