Please complete this form to provide the appropriate points of contact at your organization. This is an important form to work on before your project kicks off.

If you have any questions, please contact your Engagement Manager or helpdesk@contexture.org.
Organization Address(Required)

Billing

Works with Contexture for invoices and billing inquiries.
Name(Required)

Contract

Works with Contexture for any amendments or contract changes.
Name(Required)

Primary Point of Contact

Main point of contact that works with Contexture.
Name(Required)

Security/Privacy Officer

Name(Required)

Legal Contact

Responsible for maintaining participant's compliance with Contexture's Governing Principles and Policies. Includes receiving updates from the Contexture Help Desk and incorporating updates into internal policies and procedures.
Name(Required)

Opt In/Opt Out

Receives confirmations and answers questions about the Opt-In and Opt-Out request form.
Name(Required)

IT/Network Issues or Concerns (During Business Hours)

Contact that should be notified if there is an issue with the interface, network, or other IT issues/concerns.
Name(Required)

IT/Network Issues or Concerns (After Business Hours)

Contact that should be notified if there is an issue with the interface, network, or other IT issues/concerns.
Name(Required)

Downtime/Critical Issues

Contact that should be notified if there is a critical issue, including patient safety, as defined in the Participation Agreement.
Name(Required)

Downtime/Critical Issues (After Business Hours)

Contact that should be notified if there is an issue with the interface, network, or other IT issue/concern.
Name(Required)

HIE System Upgrades

Contact for when the HIE is upgraded including any planned or unplanned downtime.
Name(Required)
Please list the contact for your Contexture solutions below. You can skip those solutions that you do not currently have. If you are interested in adding a solution, please reach out to your Engagement Solutions Manager.

PatientCare 360/Portal

Contact authorized to add users to PatientCare 360 (which could affect billing).
Name

HISP/Direct Messaging

Contact working with Web Direct or MedAllies who will receive the Username and Password.
Name

Notifications

Contact responsible for notification if Notifications file fails.
Name

Reports/Dashboards

Contact responsible for issues with Reports and/or Dashboard Solutions.
Name
Once you have completed all required sections, please click submit