Integrated Direct Messaging

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:

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* 2. Facility Address:

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* 3. Contact Name:

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* 4. Contact Telephone Number:

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* 5. Contact Email Address:

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* 6. Are you currently using a standalone Direct Messaging application?

Yes

No

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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?

Yes

No

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

Yes

No

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

PDF Files

Excel Files

Zip Files

Other (please specify)