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<div id="mc_embed_signup"><!-- [et_pb_line_break_holder] --> <h3><!-- [et_pb_line_break_holder] --> Fill out the form below to speak to an outreach expert.<!-- [et_pb_line_break_holder] --> </h3><!-- [et_pb_line_break_holder] --> <form action="https://providertech.us8.list-manage.com/subscribe/post?u=53089c0c3ead5565b7109e99f&id=39cb30bd18" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate><!-- [et_pb_line_break_holder] --> <div id="mc_embed_signup_scroll"><!-- [et_pb_line_break_holder] --> <div class="indicates-required"><span class="asterisk">*</span> indicates required</div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-FNAME">First Name <span class="asterisk">*</span></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="FNAME" class="required" id="mce-FNAME"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-LNAME">Last Name </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="LNAME" class="" id="mce-LNAME"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-EMAIL">Email Address <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --> </label><!-- [et_pb_line_break_holder] --> <input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-PHONE">Phone Number</label><!-- [et_pb_line_break_holder] --> <input type="text" name="PHONE" class="" value="" id="mce-PHONE"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE7">Zip Code </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="MMERGE7" class="" id="mce-MMERGE7"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-ORG">Organization Name </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="ORG" class="" id="mce-ORG"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-SPECIALITY">Organization Type / Speciality </label><!-- [et_pb_line_break_holder] --> <select name="SPECIALITY" class="" id="mce-SPECIALITY"><!-- [et_pb_line_break_holder] --> <option value=""></option><!-- [et_pb_line_break_holder] --> <option value="Cardiology">Cardiology</option><!-- [et_pb_line_break_holder] --> <option value="Dermatoloty">Dermatoloty</option><!-- [et_pb_line_break_holder] --> <option value="Family Practive">Family Practice</option><!-- [et_pb_line_break_holder] --> <option value="FQHC">FQHC</option><!-- [et_pb_line_break_holder] --> <option value="Multi-Speciality">Multi-Speciality</option><!-- [et_pb_line_break_holder] --> <option value="OB/GYN">OB/GYN</option><!-- [et_pb_line_break_holder] --> <option value="Opthamology">Opthamology</option><!-- [et_pb_line_break_holder] --> <option value="Payer">Payer</option><!-- [et_pb_line_break_holder] --> <option value="Pediatrics">Pediatrics</option><!-- [et_pb_line_break_holder] --> <option value="Podiatry">Podiatry</option><!-- [et_pb_line_break_holder] --> <option value="Urgent Care">Urgent Care</option><!-- [et_pb_line_break_holder] --> <option value="Other">Other</option><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-PROVIDERS">Number of Providers </label><!-- [et_pb_line_break_holder] --> <select name="PROVIDERS" class="" id="mce-PROVIDERS"><!-- [et_pb_line_break_holder] --> <option value=""></option><!-- [et_pb_line_break_holder] --> <option value="1 - 6 Providers">1 - 6 Providers</option><!-- [et_pb_line_break_holder] --> <option value="7-20 Providers">7-20 Providers</option><!-- [et_pb_line_break_holder] --> <option value="21- 100 Providers">21- 100 Providers</option><!-- [et_pb_line_break_holder] --> <option value="100 - 250 Providers">100 - 250 Providers</option><!-- [et_pb_line_break_holder] --> <option value="250+ Providers">250+ Providers</option><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div id="mce-responses" class="clear"><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-error-response" style="display:none"></div><!-- [et_pb_line_break_holder] --> </div> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><!-- [et_pb_line_break_holder] --> <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_53089c0c3ead5565b7109e99f_39cb30bd18" tabindex="-1" value=""></div><!-- [et_pb_line_break_holder] --> <input type="hidden" name="SSOURCE" id="SSOURCE" value="CHUG Exp Request"> <!-- Setting the source --><!-- [et_pb_line_break_holder] --> <input type="hidden" name="EMR" id="EMR" value="GE Centricity"> <!-- Setting hidden value EMR --><!-- [et_pb_line_break_holder] --> <div class="clear"><input type="submit" value="Submit" name="subscribe" id="mc-embedded-subscribe" class="et_pb_button button"></div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-success-download" style="display:none;"> <!-- Success Message --><!-- [et_pb_line_break_holder] --> One of our outreach experts will be in touch with you shortly.<!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><script type='text/javascript' src='https://www.providertech.com/wp-content/themes/providerTech/js/mailchimp-custom-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[0]='EMAIL';ftypes[0]='email';fnames[4]='PHONE';ftypes[4]='phone';fnames[7]='MMERGE7';ftypes[7]='zip';fnames[3]='ADDRESS';ftypes[3]='address';fnames[5]='EMR';ftypes[5]='text';fnames[6]='SOURCE';ftypes[6]='text';fnames[9]='ORG';ftypes[9]='text';fnames[10]='SPECIALITY';ftypes[10]='dropdown';fnames[8]='PROVIDERS';ftypes[8]='dropdown';}(jQuery));var $mcj = jQuery.noConflict(true);</script><!-- [et_pb_line_break_holder] --><!--End mc_embed_signup-->

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