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Otherwise, HealthInfoNet’s Client Engagement team may require the requestor to re-submit this form upon the proper authorization."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":12},"layout":"default","localId":"6f64a53b-9884-4815-a2d8-7ed2712e8993"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":15},"layout":"default","localId":"abc94d97-6622-4594-a67f-a5ef133fd4ea"}},{"type":"heading","attrs":{"level":2,"localId":"33f5a578-6596-476f-9443-2ec8b0040fac"},"content":[{"type":"text","text":"HIPAA Status"}]},{"type":"paragraph","attrs":{"localId":"fe75cf5a-ab92-41b0-b793-e61a9a4f5e42"},"content":[{"type":"text","text":"Provide information about the requesting organization’s HIPAA covered entity status to inform participation eligibility. "}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":16},"layout":"default","localId":"d8384bac-f89f-467e-a42b-8cb521615bbf"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2,"localId":"c5263e93-ea74-4bbd-8bbf-4c0b8df186de"},"content":[{"type":"text","text":"Participation Request Close"}]},{"type":"paragraph","attrs":{"localId":"677770a9-1f36-4f2e-8e10-2cbcf0beedad"},"content":[{"type":"text","text":"Thank you for your interest in joining Maine's statewide Health Information Exchange. At this time, only organizations that identify as a HIPAA covered entity healthcare provider with a treating patient relationship are eligible for participation. "}]},{"type":"paragraph","attrs":{"localId":"cc5fad6d-15d4-4b81-853a-68ecde2d9526"},"content":[{"type":"text","text":"For questions, please contact HealthInfoNet's Client Engagement team ("},{"type":"text","text":"clientengagement@hinfonet.org","marks":[{"type":"link","attrs":{"href":"mailto:clientengagement@hinfonet.org"}}]},{"type":"text","text":"). "}]}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2,"localId":"77e5cabd-a36c-4436-b2a9-e5c8cc88918f"},"content":[{"type":"text","text":"General Information"}]},{"type":"paragraph","attrs":{"localId":"c3413ef3-d4c0-4625-b062-c18d120c6ee3"},"content":[{"type":"text","text":"Provide additional general information about the requesting 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Treated"}]},{"type":"paragraph","attrs":{"localId":"c167a772-9089-4899-88c2-51bde2656646"},"content":[{"type":"text","text":"Provide information about the individuals treated by the requesting organization."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":29},"layout":"default","localId":"33df735d-d7ec-4580-aeca-49f1bb2d3aba"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":31},"layout":"default","localId":"90044dc9-51d5-4a9b-9f65-4060c68f105e"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":4,"localId":"0b5f8bd2-aa31-4c04-9771-a1d9ec4bb47e"},"content":[{"type":"text","text":"Instructions"}]},{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","attrs":{"localId":"0b5be351-d05d-40f2-a940-e45494167bd2"},"content":[{"type":"text","text":"If the requesting 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Capabilities"}]},{"type":"paragraph","attrs":{"localId":"4d3f2bf1-2ae7-47a7-8878-3bc36cc4d13b"},"content":[{"type":"text","text":"Provide information about the requesting organization’s technical capabilities to support participation."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":44},"layout":"default","localId":"550c12c7-fcbe-46de-ad6b-c60a0c3e5c70"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":47},"layout":"default","localId":"f4b30ffc-077b-494a-a29d-b0fabf2dc6da"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":48},"layout":"default","localId":"1393bb80-ffd6-4692-af48-c2d8c54c89b1"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":49},"layout":"default","localId":"8fb3f9be-92d2-420b-a127-b3aa4388a236"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":46},"layout":"default","localId":"a200f075-5c9e-4950-8b59-15400673fd10"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":50},"layout":"default","localId":"b95dceca-1ef0-44ec-86df-0874872ef686"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2,"localId":"c38f2643-4877-4e3c-b8f2-a21ec7372636"},"content":[{"type":"text","text":"Next Steps"}]},{"type":"paragraph","attrs":{"localId":"c2272a61-8d58-4d19-b6a8-b81674db4000"},"content":[{"type":"text","text":"Please submit this Participation Request form by selecting the “Send” button below. "}]},{"type":"paragraph","content":[{"type":"text","text":"We will be in touch shortly once we have had an opportunity to review your organization's form submission. For questions, please contact HealthInfoNet's Client Engagement team ("},{"type":"text","text":"clientengagement@hinfonet.org","marks":[{"type":"link","attrs":{"href":"mailto:clientengagement@hinfonet.org"}}]},{"type":"text","text":")."}],"attrs":{"localId":"a0039b90-a658-47ce-908c-7f805c2f5970"}},{"type":"paragraph","content":[{"type":"text","text":"Thank you for connecting with HealthInfoNet!"}],"attrs":{"localId":"d975df97-ac2c-4434-ad02-f548c7444489"}},{"type":"paragraph","content":[]},{"type":"paragraph","content":[{"type":"text","text":"Note: ","marks":[{"type":"em"},{"type":"strong"}]},{"type":"text","text":"If the form does not appear to immediately process upon submission, please review the form inputs above to confirm there are no validation errors requiring remediation. 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Organization Information"}]},{"type":"paragraph","content":[{"type":"text","text":"Provide information about the organization at which the requestor serves and which is subject to this participation request (i.e., “the requesting organization”). "}],"attrs":{"localId":"d370893b-62d1-4aff-9a85-a68023a63267"}},{"type":"layoutSection","content":[{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":9},"layout":"default","localId":"32f5a062-85a4-4b61-8650-7b7f4dde75bc"}}]},{"type":"layoutColumn","attrs":{"width":50},"content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":10},"layout":"default","localId":"eafebe18-20be-444e-815c-a490bbc40cab"}}]}]}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":4,"localId":"23da0b7b-72fa-453e-b9b5-f690b5ee656d"},"content":[{"type":"text","text":"Note: Authorization to Submit Requests","marks":[{"type":"textColor","attrs":{"color":"#bf2600"}}]}]},{"type":"paragraph","attrs":{"localId":"c44e8b43-51b0-46a4-b7ec-767d5413197b"},"content":[{"type":"text","text":"It is strongly recommended that the requestor receives authorization from the requesting organization’s leadership before submitting this form. Otherwise, HealthInfoNet’s Client Engagement team may require the requestor to re-submit this form upon the proper authorization."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":12},"layout":"default","localId":"6f64a53b-9884-4815-a2d8-7ed2712e8993"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":15},"layout":"default","localId":"abc94d97-6622-4594-a67f-a5ef133fd4ea"}},{"type":"heading","attrs":{"level":2,"localId":"33f5a578-6596-476f-9443-2ec8b0040fac"},"content":[{"type":"text","text":"HIPAA Status"}]},{"type":"paragraph","attrs":{"localId":"fe75cf5a-ab92-41b0-b793-e61a9a4f5e42"},"content":[{"type":"text","text":"Provide information about the requesting organization’s HIPAA covered entity status to inform participation eligibility. "}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":16},"layout":"default","localId":"d8384bac-f89f-467e-a42b-8cb521615bbf"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2,"localId":"c5263e93-ea74-4bbd-8bbf-4c0b8df186de"},"content":[{"type":"text","text":"Participation Request Close"}]},{"type":"paragraph","attrs":{"localId":"677770a9-1f36-4f2e-8e10-2cbcf0beedad"},"content":[{"type":"text","text":"Thank you for your interest in joining Maine's statewide Health Information Exchange. At this time, only organizations that identify as a HIPAA covered entity healthcare provider with a treating patient relationship are eligible for participation. "}]},{"type":"paragraph","attrs":{"localId":"cc5fad6d-15d4-4b81-853a-68ecde2d9526"},"content":[{"type":"text","text":"For questions, please contact HealthInfoNet's Client Engagement team ("},{"type":"text","text":"clientengagement@hinfonet.org","marks":[{"type":"link","attrs":{"href":"mailto:clientengagement@hinfonet.org"}}]},{"type":"text","text":"). "}]}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2,"localId":"77e5cabd-a36c-4436-b2a9-e5c8cc88918f"},"content":[{"type":"text","text":"General Information"}]},{"type":"paragraph","attrs":{"localId":"c3413ef3-d4c0-4625-b062-c18d120c6ee3"},"content":[{"type":"text","text":"Provide additional general information about the requesting 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