CareMESH Pre-Enrollment Sign-Up Form

careMESH? is a HIPAA-compliant platform that shares information with you about your patients�� admission and discharge summaries, referrals and other transitions of care. Please complete and submit our pre-enrollment form to start your careMESH registration.

Click here for a complete overview of the careMESH? platform.

For general information, please contact your TGH physician business development representative or email physicianrelations@tgh.org.

For technical questions, please contact careMESH at (703) 691-6128 or support@caremesh.com.

* denotes mandatory fields

1 Start 2 Page 2 3 Complete

Name of Organization or Practice *(Required)

This is the name that will be used by other healthcare organizations to find you in the careMESH National Provider Directory.

Overview *(Required)

Provide a brief overview of your group or practice to help readers better understand your services.

Logo

Files must be less than 32 MB.
Allowed file types: jpg jpeg png pdf.

EHR

(Optional) Which EHR does your Practice use?

Practice TIN (Tax ID Number) *(Required)

Office Locations

Location 1

Name *(Required)

Address *(Required)

Address 2

City *(Required)

State *(Required)

Zip *(Required)

Phone *(Required)

Fax

Additional Locations

Yes

Location 2

Name

Address

Address 2

City

State

Zip

Phone

Fax

Location 3

Name

Address

Address 2

City

State

Zip

Phone

Fax

Location 4

Name

Address

Address 2

City

State

Zip

Phone

Fax

Designated Super User

For your Group or Practice, a super user is the designated resource who will be the primary point of contact for careMESH enrollment and will work directly with careMESH to ensure system activation. Beyond activation, the Super User will add or delete users, support practice users and perform other basic account functions

Super User

First Name *(Required)

Last Name *(Required)

Title *(Required)

Primary Work Location

Email *(Required)

Address *(Required)

Address 2

City *(Required)

State *(Required)

Zip *(Required)

Phone *(Required)

Fax

Super User NPI (if applicable):

Agreement

The term Organization or Practice refers to the name of the organization specified on Page 1 of this form.

By signing below I confirm that careMESH accounts, which may include access to Protected Health Information as defined by the Code of Federal Regulations (45 CFR 160.103), should be created for all those individuals specified on Page 3 of this form and each individual user will be required to accept the Terms of Use of the careMESH Service prior to accessing the service.

I also confirm that (a) I am authorized to access and grant access to patient information on behalf of the Organization or Practice; (b) the information contained in this application is accurate and correct; (c) that the Organization or Practice that I represent is a HIPAA covered entity or business associate; (d) that I or my organization will verify the identity of all users added to careMESH on behalf of the Organization or Practice, and (e) that I will manage the access of those users including withdrawal of access, as appropriate.

*(Required)

By submitting this form, you are agreeing to our agreement terms.