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<h2>This form is to be completed by the CEO, President, GM, Owner, MD or an Executive of the organization or office.</h2><p>*Required Fields</p><div class=\'form-group\'><label for=\'FormField2_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>Organization name<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField4_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  hidden-label\'>Address 2</label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField29_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>E-Mail<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField10_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>CEO/Pres/GM/Owner/MD<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField10_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField10_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'CEO/Pres/GM/MD/Owner is required.\' data-export-label=\'CEO_Pres_GM_Owner_MD\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField11_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>Website URL (Enter &#39;None&#39; if applicable)<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField11_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField11_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'website_URL\'  placeholder=\'\'  />\
</div></div><h2>Please provide the following information about your organization</h2><div class=\'form-group OrganizationType\'><label for=\'FormField13_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>1. Type of Organization (please check one)<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField13_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField13_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Type of organization is required.\' data-export-label=\'1_Type_of_Organization\' ><option value=\'\' selected>( Please Select )</option><option value=\'Physician Practice\'>Physician Practice</option><option value=\'Medical Clinic\'>Medical Clinic</option><option value=\'Billing Office\'>Billing Office</option><option value=\'Home Health\'>Home Health</option><option value=\'Skilled Nursing Facility\'>Skilled Nursing Facility</option><option value=\'Hospice\'>Hospice</option><option value=\'Chiropractic Medicine\'>Chiropractic Medicine</option><option value=\'Alternative Medicine\'>Alternative Medicine</option><option value=\'Hospital\'>Hospital</option><option value=\'Public Health Clinic\'>Public Health Clinic</option><option value=\'Safety Net Provider/Organization\'>Safety Net Provider/Organization</option><option value=\'Other\'>Other</option></select></div></div><div class=\'form-group OrganizationTypeOther\'><label for=\'FormField26_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>If Other, please list</label><div>\
<input type=\'text\' name=\'FormField26_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField26_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'If_Other_please_list\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField15_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>2. Describe affiliation with Cottage Health<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField16_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>3. Purpose(s) for access to CottageOne Link<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField16_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField16_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control input-large \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'3_Purposes_for_access_to_CottageOne_Link\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField17_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>4. Number of employees who require access<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField17_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField17_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control input-small \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'4_Number_of_employees_who_require_access\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField39_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>5. Name of individual(s) authorized as Site Administrator(s), with the responsibility and security to manage the accounts for other users at the site. This includes editing users’ demographics, setting passwords, and requesting, extending, and/or terminating user accounts on behalf of your practice or organization.<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField39_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField39_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control textarea-medium\' required data-msg-required=\'This field is required.\'  data-export-label=\'5_Individual_or_signatory_authorized_to_request_employee_access\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField19_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>6. Site Administrators’ Individual Title(s)<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField19_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField19_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'6_Site_Administrators_Individual_Title\'  placeholder=\'\'  />\
</div></div><h2>For physician offices, clinics, or organizations with physicians on staff, please list the names of the physicians below</h2><div class=\'form-group\'><label for=\'FormField25_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>Physician names<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField25_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField25_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'form-control textarea-medium\' required data-msg-required=\'This field is required.\'  data-export-label=\'Physician_names\'  placeholder=\'\'></textarea>\
</div></div><h1>Agreement for Use of Cottage Health&apos;s Online Services</h1><p><strong>Acknowledgment:</strong></p><p><br></p><p>By Undersigned&rsquo;s signature below, Undersigned agrees that he/she has <a href=\'https://www.cottagehealth.org/wip/link-form/agreement-of-use-of-online-services/\' target=\'_blank\'>read and understands this Agreement</a> 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=\'85f0101d-2a13-4994-b85a-04244bc0ea1e_FormField31_beb1c4a9-e212-40cc-a136-a2b3ae0e501d_checkbox_31\' id=\'FormField31_beb1c4a9-e212-40cc-a136-a2b3ae0e501d_1\' class=\'fo-right-margin-5\' data-export-label=\'Acknowledgment_checkbox\' ><label for=\'FormField31_beb1c4a9-e212-40cc-a136-a2b3ae0e501d_1\'>I have read and understand the Acknowledgment</label></div></div></div></div><h2>Signature</h2><div class=\'form-group\'><label for=\'FormField37_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>Electronic Signature of CEO/Pres/GM/Owner/MD<span class=\'fb-required\'>*</span></label><div>\
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<div class=\'formHelp\'>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=\'FormField38_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>Title<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField22_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' class=\'control-label  \'>Today&#39;s Date<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField22_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' id=\'FormField22_beb1c4a9-e212-40cc-a136-a2b3ae0e501d\' 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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