Children’s Health Network: Request for Application

Apply for Membership into Children's Health Network (CHN)


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  • Requestor Information







  • Your email address will be your portal username. When your account is activated by our staff, you will need this to log in to the portal.
  • Please record this password in a safe place. When your account is activated by our staff, you will need this to log in to the portal.













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  • Provider Information








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  • If not board certified, please explain.

































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    If the start date is unknown, it is preferred that you enter an estimated date.
  • Contact Us

  • If you have any questions or concerns regarding the purpose of this form, or its completion, please do not hesitate to contact us at 402-955-8932
    or CHN@childrensomaha.org

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