User Accounts

Organization/practice name:

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* 1. Organization/practice name:

Organizational NPI number (if applicable):

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* 2. Organizational NPI number (if applicable):

Entity Security Administrator Information
*Please fill in user account information for each Web Mail account your organization/practice needs.

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* 3. Entity Security Administrator Information
*Please fill in user account information for each Web Mail account your organization/practice needs.

Does the Entity Security Administrator need an account?

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* 4. Does the Entity Security Administrator need an account?

How many total user accounts on HSX MirthMail (including the one above) does the organization/practice need created?

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* 5. How many total user accounts on HSX MirthMail (including the one above) does the organization/practice need created?

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