GHC EpicLink Employer Group Site Coordinator Agreement

GHC EpicLink Employer Group Site Coordinator Agreement
Group Health Cooperative of South Central Wisconsin (GHC-SCW) offers its fully-insured employer groups access to GHC EpicLink to assist with employer insurance-related activities. By signing this Agreement, the named Organization, its designated Site Coordinator and any GHC EpicLink users within the Organization agrees to the stated terms, conditions and responsibilities set forth below.
Organization Name*
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Phone Number*
Organization Tax ID Number(s)*
Site Coordinator Full Name*
Site Coordinator Job Title*
Site Coordinator Private Work Email*
*Please ensure this is a private email address and not shared email address.
Site Coordinator Work Phone Number*
BY SIGNING BELOW, I AM CERTIFYING THAT I AM AUTHORIZED BY MY ORGANIZATION TO SIGN THIS AGREEMENT AND ACKNOWLEDGE AND AGREE TO THE TERMS, CONDITIONS, AND RESPONSIBILITIES SET FORTH IN THIS AGREEMENT.
Signature*

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Date*

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Date
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