Category * Job ApplicantEmployeePhysician/Provider Registration Form for Job Applicants Name* First Last Email* Primary Affiliation (please choose facillty from dropdown)*AmeriCare Home Health of BryanAmeriCare Home Health of DefianceAmeriCare Home Health of FindlayAmeriCare Home Health of FremontAmeriCare Home Health of ToledoAnchor Home Health of Greater ClevelandAnchor Home Health of Greater ColumbusAlpine House of ColumbusAlpine House of RavennaAlpine House of ToledoCareTronicPrideland HoldingsToledo Pet FarmSAI GroupRequesting*SNH#EMPLOYEE LOGIN & COM# This iframe contains the logic required to handle Ajax powered Gravity Forms. Registration Form for Employees Name* First Last Email* Primary Affiliation (please choose facility)*AmeriCare Home Health of BryanAmeriCare Home Health of DefianceAmeriCare Home Health of FindlayAmeriCare Home Health of FremontAmeriCare Home Health of ToledoAnchor Home Health of Greater ClevelandAnchor Home Health of Greater ColumbusAlpine House of ColumbusAlpine House of RavennaAlpine House of ToledoCareTronicPrideland HoldingsToledo Pet FarmSAI GroupRequesting*SNH#EMPLOYEE LOGIN & COM#CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Registration Form for Providers Name* First Last Email* Primary Affiliation (please choose facillty from dropdown)*AmeriCare Home Health of BryanAmeriCare Home Health of DefianceAmeriCare Home Health of FindlayAmeriCare Home Health of FremontAmeriCare Home Health of ToledoAnchor Home Health of Greater ClevelandAnchor Home Health of Greater ColumbusAlpine House of ColumbusAlpine House of RavennaAlpine House of ToledoCareTronicSelect*A. PROVIDER LOG‐IN ONLY*B. PROVIDER LOG‐IN & E‐MAIL ID**C. PROVIDER LOG‐IN AND FORWARD CORRESPONDENCES TO MY E‐MAIL ADDRESS:**** If you selected the option (C.), by checking this box, you ensure that your e‐mail security measures are compliant to HIPAA provisions. * Provides access to telehealth reports and commonly used patient forms through the provider page of p y p f g p p g f this website. No e‐mails reports are sent. **Provides access to telehealth reports, commonly used forms and e‐mail reports/ correspondences concerning your patients via the provider page of this website. *** Provides access to telehealth reports and commonly used patient forms through the provider page of this website. E‐mail reports are sent directly to the provider’s e‐mail address* By checking this box, the health care “facility” (stated in the “affiliation”) and I agree to use the provider log‐in*and/or e‐mail address provided** to me for the sole purpose of communicating and coordinating care via reports/ notes pertaining to my patients. Also, the “facility” and I agree that the provided e‐mail address does not make either party an agent or an employee of the other. By checking this box, I agree and enter into a HIPAA Business Associate Agreement with the “facility” stated above as the covered entity. All securityprecautions will be observed by both parties in order to remain HIPAA compliant. As a condition of participating in this registration process provider AGREES that he/she has read and agreed to the terms of BOTH (1) HIPAA Business AssociateAgreement and (2) the Website Provider Agreement provided above. By signing below the provider EXPRESSESLY AGREES that he/ she is bound to and shallabide by the Terms of these Agreements. If the provider does not agree to these terms, he/ she is requested to contact IT@theSAIgroup.org discuss his/herconcerns or objections. [ If the provider is granted registration, the “facility” shall be deemed to have entered into a ‘Website Provider Agreement’ and the ‘HIPAA BusinessAgreement’ with the provider]. Other Comments/ requests: This iframe contains the logic required to handle Ajax powered Gravity Forms.
