Organization Management Template - Form D Please note:.Please submit this User Request form after successfully passing all compliancy testing. This form is to be used only by those provider organizations approved to upload HIPAA files into EIM. File Transfer Service HIPAA User Request Form.Important : If an organization needs to update their legal name, change their address or merge with another organization, contact EIM/ESM User Request Form Organization Legal Name (Do Not Include Any of the following Special Characters such as & * + ( ) _ -).The following information is required to Register a New Virtual Gateway Organization: Register a New Virtual Gateway Organization Refer to EIM/ESM Instructions for more information. He or she is responsible for approving, modifying, and/or removing user access privileges for any of the VG's business services used by your organization. The Authorized Representative must designate an individual(s) to be their VG Access Administrator(s). An Authorized Representative is an individual who has the legal authority to sign on behalf of your organization, as evidenced by your organization's charter or bylaws. This information must be completed and submitted online by an Authorized Representative for your organization. New Virtual Gateway providers going live with contracts on EIM/ESM for the first time need to submit their organization information using the online Virtual Gateway Organization Management webpage.
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