Equipment ordering form (Waves 1, 2, 3) Question Title * 1. Please select your job category from one of the following options. Provider: Medical professionals providing direct patient care (i.e., physician, nurse practitioner) Clinical user: Roles directly involved in patient care or clinical support and require eCW access (i.e., receptionist, medical records clerk, medical assistant) Operational/nonclinical user: Roles supporting business operations and administration that do not require eCW access (i.e., Utilization Management Team, credentialing professional) Contact Center user: Offshore roles handling inbound and outbound communications (i.e. Inbound Contacts representative) IT Operations user: Roles related to IT support, development and infrastructure (i.e., Desktop/End User Support technician, IT project manager) Provider Clinical user Operational/nonclinical user Contact Center user IT Operations user Question Title * 2. Do you work from home or at a Conviva location? Work from home At a Conviva center Question Title * 3. If you answered "Work from home" to question No. 2, please provide your address. Address Address 2 (if needed) City State Zip code Question Title * 4. If you answered "At a Conviva center" to question No. 2, please provide the name of the center where you work. Question Title * 5. Please provide the Asset tag number of your computer that is placed on the bottom of the device. Question Title * 6. Please provide your work email address. Question Title * 7. Please provide the best phone number to reach you. Done