Genoa Online Request Access Form

Genoa Online access is for partner staff members only. It is not for consumers at this time.
  • This form must be filled out by providers or employees of community mental health organizations (centers) affiliated with Genoa in order to gain access to the Genoa Online tools for the purposes of treatment, payment and operations for consumers under their direct care.
  • A corporate email address must be used to gain access to Genoa Online. If a corporate email address is not available, the exception needs to be explained and approved by the Director of Operations and sent to
  • Passwords must change every 90 days or a user will be locked out of the system until he or she changes the password.
  • The information contained in the Genoa Online tools is protected by the same HIPAA regulations as all other PHI. Please follow the same precautions you would handling this information in any other situation.
  • It is a users’ responsibility to inform Genoa, if they are no longer going to need access to Genoa Online by emailing
Registration errors
Center Information
Account Information
Application Access

As a Genoa Online user, I shall comply with applicable provisions of the Health Insurance Portability and Accountability Act of 1996 and regulations there-under as amended from time to time ("HIPAA").

Genoa Online System Terms of Use
Genoa Website Terms of Use

Confirm Acknowledgement

Genoa Online System Terms of Use
Genoa Website Terms of Use

I hereby agree to comply with the applicable provisions in accordance with the regulations set forth in 45 C.F.R. Parts 160 and 164 issued pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”) and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act set forth in 42 U.S.C. § 17921 et seq. In addition, I shall at all times comply with the provisions of the Privacy and Security Rules applicable to me, including the minimum necessary requirements, which state that protected health information should not be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. The minimum necessary standard requires me to evaluate my practices and enhance safeguards as needed to limit unnecessary or inappropriate access to and disclosure of protected health information. Finally, should my employment be terminated, or a change in position that would make access to Genoa Online and its tools no longer permissible, I agree to notify Genoa immediately of my employment status change.