Point of Contact Info
Let's get some information about you
What is your email?
*
Name
*
First Name
Last Name
What is your title?
*
What is your role?
Phone Number
*
-
Area Code
Phone Number
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Company Details
Let's get the basics of your firm
Company's name
*
Company's website?
*
Give us a quick two sentence description of your company.
*
What services does your company proviode?
*
Administrative
Allied Health/Support
Clinical Laboratory
Cybersecurity
Facilities
Finance
Housekeeping/Facilities/Transport
HR
Interoperability
IT Hardware
IT Software
Medical
Nutrition
Operations
Pharmacy
Quality/Performance Improvement
Number of Customers?
*
What year was your company founded?
*
How many employees does your company have?
*
Company Logo
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What is your legal formation?
*
Please Select
B-Corp
C-Corp
Close Corporation
Coop
LLC
LLP
Nonprofit Corporation
Partnership
S-Corp
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Where is your company based?
Street Address
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
Does your company have offices in other locations?
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
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Tell us about your business model
Tell us a bit more about how your business works?
Do you offer multiple products?
*
Yes
No
Tell us about each product
*
Tell us about your pricing structure?
*
Who is your target customer?
*
Clinical Model
*
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Talk to us about your current progress
What are you doing now?
What is your new product pipeline?
*
What is your annual revenue
*
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A few more questions
Verify you are certified HIPAA compliant?
*
Please Select
Yes
No
Upload your most current Cyber insurance policy.
*
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Upload your most current annual risk assessment.
*
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What is the architecture of your platform?
*
What are your cloud or API integrations?
*
What devices or technical requirements are needed for your system?
*
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The next three questions are providing client references.
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Client Reference 1
Tell us a bit about some clients you have worked with
Organization or company name
*
Point of contact's name
*
Location
*
Contact email
*
Product or services being utilized
*
Client Reference 2
Tell us a bit about some clients you have worked with
Organization or company name
*
Point of contact's name
*
Location
*
Contact email
*
Product or services being utilized
*
Client Reference 3
Tell us a bit about some clients you have worked with
Organization or company name
*
Point of contact's name
*
Location
*
Contact email
*
Product or services being utilized
*
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