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</div></div><div class=\'form-group\'><label  class=\'control-label  \'>Select only ONE that best describes your primary job duties. (Click link below to review definitions).<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'separate\'><input type=\'radio\' value=\'Billing Staff\' required data-msg-required=\'This field is required.\' name=\'checkbox16\' id=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_1\' class=\'right\' data-export-label=\'User_profile\' ><label for=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_1\'>Billing Staff</label></div><div class=\'separate\'><input type=\'radio\' value=\'Clinical Support Staff\' required data-msg-required=\'This field is required.\' name=\'checkbox16\' id=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_2\' class=\'right\' data-export-label=\'User_profile\' ><label for=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_2\'>Clinical Support Staff</label></div><div class=\'separate\'><input type=\'radio\' value=\'Front Desk\' required data-msg-required=\'This field is required.\' name=\'checkbox16\' id=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_3\' class=\'right\' data-export-label=\'User_profile\' ><label for=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_3\'>Front Desk</label></div><div class=\'separate\'><input type=\'radio\' value=\'Provider\' required data-msg-required=\'This field is required.\' name=\'checkbox16\' id=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_4\' class=\'right\' data-export-label=\'User_profile\' ><label for=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_4\'>Provider</label></div><div class=\'separate\'><input type=\'radio\' value=\'ROI Requester\' required data-msg-required=\'This field is required.\' name=\'checkbox16\' id=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_5\' class=\'right\' data-export-label=\'User_profile\' ><label for=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_5\'>ROI Requester</label></div><div class=\'separate\'><input type=\'radio\' value=\'Site Administrator\' required data-msg-required=\'This field is required.\' name=\'checkbox16\' id=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_6\' class=\'right\' data-export-label=\'User_profile\' ><label for=\'FormField16_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_6\'>Site Administrator</label></div></fieldset></div></div></div><p><a href=\'https://www.cottagehealth.org/wip/cottage-one-link-access/#definitions\' target=\'_blank\'>Click here for profile definitions</a></p><h2>Accessing Records</h2><p>Please be advised that access to all patient records is tracked through an audit process. Inappropriate access is a violation of system policies and law, and may result in immediate termination of system access and legal penalties.</p><h1>Universal Confidentiality of Information Acknowledgment</h1><h2>Acknowledgment:&nbsp;</h2><p>By Undersigned&rsquo;s signature below, Undersigned agrees that he/she has <a href=\'https://www.cottagehealth.org/wip/link-form/universal-confidentiality-of-information-acknowledgement/\' target=\'_blank\'>read and understands this Acknowledgment</a>&nbsp;as a condition of Undersigned&rsquo;s employment or engagement to provide services at/to CH and/or its patients (provided that CH acknowledges that no consideration has or will be provided to me in connection with this Acknowledgment). Undersigned understands and acknowledges that Cottage Health may limit or terminate access to CH information at any time.</p><div class=\'form-group\'><label  class=\'control-label  hidden-label\'>Acknowledgment_Checkbox<span class=\'fb-required\'>*</span></label><div><div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'I have read and understand the Acknowledgment\' required data-msg-required=\'Acknowledgment is required.\' name=\'311d9d60-1418-4be2-a634-faf12574ca4c_FormField27_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_checkbox_27\' id=\'FormField27_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_1\' class=\'fo-right-margin-5\' data-export-label=\'Acknowledgment_Checkbox\' ><label for=\'FormField27_0cf84ecf-908c-4d24-8ba7-3947f35c74a4_1\'>I have read and understand the Acknowledgment</label></div></div></div></div><div class=\'form-group\'><label for=\'FormField17_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' class=\'control-label  \'>Individual End User&#39;s electronic signature<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField17_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' id=\'FormField17_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'End user&#39;s electronic signature is required.\' data-export-label=\'End_User_Signature\'  placeholder=\'\'  />\
<div class=\'formHelp\'>Please type First and Last Name. I acknowledge that my electronic signature has the same legal force and effect as my manual signature.</div></div></div><div class=\'form-group\'><label for=\'FormField19_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' class=\'control-label  \'>Site Administrator&#39;s electronic signature<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField19_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' id=\'FormField19_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'Authorized_Signature\'  placeholder=\'\'  />\
</div></div><p>Please type First and Last Name. I acknowledge that my electronic signature has the same legal force and effect as my manual signature. <span style=\'color:red\'><strong>(Must be the individual named on your Organization Profile Form (box 5) who approves your access to patient data)</strong></span></p><div class=\'form-group\'><label for=\'FormField21_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' class=\'control-label  \'>Today&#39;s Date<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField21_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' id=\'FormField21_0cf84ecf-908c-4d24-8ba7-3947f35c74a4\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'This field is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Todays_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div>\
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