Request Additional Facility Credentials

Clients should use this page to request credentials for a new facility. You should expect the new credentials to be sent to you within 2 business days.

Client Company Name *
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Client Contact *
This is your name in case we need to contact you.
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Client Contact Email *
Your email address so we can contact you
Please enter a valid email address.
Client Contact Phone *
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Production Launch Date
When you expect this facility to go live with the CoroHealth's services
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Facility Name *
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Facility/Hospital ID#
Your ID for this facility
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Facility Type
Hospital, SNF, etc.
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IP address block *
From what IP address(es) will this facility access our services?
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Facility Address *
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Facility City *
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Facility State *
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Facility Zip *
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Facility Email Address *
a contact at the facility
Please enter a valid email address.
Technical Contact Name *
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Technical Contact Email *
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Technical Contact Phone *
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Billing Contact Name *
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Billing Contact Email *
Please enter a valid email address.
Billing Contact Phone *
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