Encounter Alerts Messaging Enrollment Form

ENCOUNTER ALERTS MESSAGING ENROLLMENT FORM

 All ConnectVirginia Encounter Alerts Messaging Organizations must assert that they are either (1) a valid, legal entities in good standing in the Commonwealth of Virginia or (2) a local, state or Federal government agency. Organizations must have a legitimate reason to send and receive Protected Health Information (PHI).

 Each organization must employ at least one health care provider who is licensed, certified or registered by the Virginia Department of Health Professions and holds a license, certificate or registration that is in good standing

 Each Organization can identify users who must be under the direction and control of the Organization to access the Organization’s ConnectVirginia Encounter Alerts Messaging Inbox (“Delegate End Users”). The Organization is responsible for all activities of their Delegate End User(s) with respect to ConnectVirginia Encounter Alerts Messaging.

 One of the organization’s Delegate End Users must be designated to serve as the Site Administrator (SA) who is responsible for maintaining accurate enrollment information and notifying ConnectVirginia of changes, including changes to the organization’s Site Administrator and/or Delegate End User(s).

 ALL users will be required to accept the ConnectVirginia Encounter Alerts Messaging End User License Agreement prior to using Connect Virginia Encounter Alerts Messaging.

 This Enrollment Form must be completed by an individual who is authorized to act on behalf of the organization.

SUBMIT COMPLETED FORM AND CERTIFICATE OF GOOD STANDING (if applicable) BY:

Email: [email protected] Mail: ConnectVirginia Enrollment, 4900 Cox Road, Suite 245, Fax: (804) 665-2497 or Glen Allen, VA 23060

ConnectVirginia Encounter Alerts Messaging Enrollment 10 14 2014 Page 1 of 3

4900 Cox Road, Suite 245 Glen Allen, VA 23060 | Phone: 804.955.1788 | Fax: 804.665.2497 ENCOUNTER ALERTS MESSAGING ENROLLMENT FORM Part 1: ORGANIZATION INFORMATION Identify the Primary Contact for ConnectVirginia Encounter Alerts Messaging who attests to being in Good Standing with the Virginia SCC:

Organization Name: ☐State Agency ☐ Virginia Legal Entity

Organization’s NPI Number (If Applicable): Number of Providers served by this account:

Organization Address Line 1:

Organization Address Line 2:

City: State: Zip Code:

Primary Contact:

Title: Phone Number: Email Address: Organization’s Health Professional’s Name (Required, if License Number (Required): NPI Number (Required): Applicable):

Is your organization in Good Standing with the SCC? SCC Number:

Part 2: END USER AND AUTHENTICATION INFORMATION

Each Encounter Alerts Messaging user is issued a username and a temporary password. Each user can choose to receive a notification when new messages arrive in their Encounter Alerts Messaging account. For these purposes, each user must have a unique e-mail address and/or an SMS enabled mobile phone number to receive the password and notification alerts.

Mobil Receive Mobile Notification User Name e Email Address Notificatio Number Method Carrier n Alerts Email, 804-123- Verizo Ex. Jane Doe [email protected] Yes or No Mobile, or 4567 n Both Site Administrator**: - - - - -

Delegate Users: - - - - -

4900 Cox Road, Suite 245 Glen Allen, VA 23060 | Phone: 804.955.1788 | Fax: 804.665.2497 **Site Administrator is responsible for maintaining accurate enrollment information and communicating changes to ConnectVirginia.

The undersigned applicant warrants, represents, and attests that all facts and information provided are accurate, current, complete and not misleading and that he or she:

1. Has completely and accurately represented his or her identity; 2. Is authorized to act on behalf of the organization 3. Represents an organization that employs at least one health care provider who is licensed, certified or registered by the Virginia Department of Health Professions and is in good standing with the Commonwealth’s SCC

Signature: Date:

4900 Cox Road, Suite 245 Glen Allen, VA 23060 | Phone: 804.955.1788 | Fax: 804.665.2497