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:
(Required.)
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2.
Facility Address:
(Required.)
*
3.
Contact Name:
(Required.)
*
4.
Contact Telephone Number:
(Required.)
*
5.
Contact Email Address:
(Required.)
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6.
Are you currently using a standalone Direct Messaging application?
(Required.)
Yes
No
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.)
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?
(Required.)
Yes
No
10.
Which of the following file attachment formats does your EHR support?
PDF Files
Excel Files
Zip Files
Other (please specify)