Instructions for completing the Identity Verification Form by an Authorized Representative of the Organization To be completed by an Authorized Representative This form must be completed by an Authorized Representative (a person who has signing authority on behalf of the organization) in its entirety and notarized by a current/licensed notary public. You must present two types of identification from the list below (one must be a photo ID) to the notary, as proof of identity. The Authorized Representative or a Point of Contact designated by the Authorized Representative is responsible for managing the Direct Secure Messaging Organization account and approving Suborganization, Individual, and Delegate accounts associated with the Organization. The following types of identification may be used, if they are current. A current document issued by the federal government or a state, county, municipal or other local government and containing the person’s photograph, signature and physical description A current driver license or current identity card issued by any state A current United States passport or a current officially recognized passport of a foreign country. A United States passport means a US passport and a US passport card issued by the US Department of State. A current United States military identification card or draft record A current identity card issued by a federally recognized Indian tribe Voter’s Registration card Birth Certificate US Coast Guard Merchant Mariner Card US Citizen ID Card (Form I-197) To be completed by an Authorized Representative Authorized Representative Name Authorized Representative Title Authorized Representative E-mail Address Business Phone Number Fax Number Organization Name Organization Type (Check below) Hospital Provider Practice/Clinic Health Plan Other If Other (Specify) Organization Mailing Address City State Zip Code HIPAA Covered Entity Business Associate Point of ContactComplete this section if you would like to designate an individual other than yourself as the Point of Contact for your Organization with CareAccord. This individual would be responsible for managing the Organization account and approving registrations which are designated as affiliates of the Organization. Point of Contact Name Point of Contact Title Point of Contact Email Address Point of Contact Phone Number Fax Number Authorized Representative Initials CAPTCHAThis question is for testing whether you are a human visitor and to prevent automated spam submissions.