Enrollment Form

Please fill out the form below to submit your enrollment. Upon completion, your form will be sent to your Account Manager for processing.

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1. Facility Name: (Required.)

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2. Facility Address: (Required.)

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3. Contact Name: (Required.)

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4. Contact Telephone Number: (Required.)

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5. Contact Email Address: (Required.)

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6. Are you currently using a standalone Direct Messaging application? (Required.)

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7. If you already using a standalone Direct Messaging application, which one are you using?

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8. Does your organization have addresses that support Direct Messaging already set-up? (Required.)

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9. If you have setup addresses that support Direct Messaging, are you aware of whether they are DirectTrust addresses? (Required.)

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10. Which of the following file attachment formats does your EHR support?

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