Please watch the following Orientation video then fill out the form below once complete.

Please fill out the form below to confirm you have viewed the video with your attestation.
Thank you.


(Provider type examples: PCP, Cardiologist, Nurse Practitioner, Behavioral Health (CHMC, nonCMHC or BHSO)

(ex. 123-456-7890, (123) 456-7890, 1234567890)
*If you do not have a phone number, enter 000-000-0000

(ex. 123-456-7890, (123) 456-7890, 1234567890)
*If you do not have a phone number, enter 000-000-0000

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