All organizations requesting access to the Virtual Gateway must complete, sign, and return this information to the Virtual Gateway.

Virtual Gateway Business Service(s): _________________________________________________________

Legal Organization Name:  	
Street Address:   	
City, State, Zip Code:  	
Phone Number:  	Fax Number:  	
		
Access Administrator Profile Information 		
Name:  	Check one box to either designate an individual as an Access Administrator or remove him/her if they no longer function as an Access Administrator.  	
Email Address:  		
Work Phone Number:  	  Designate*
  Remove	
Access Administrator’s Signature Required:
By signing this form, you agree to have read and accepted the terms and conditions applicable to Access Administrators as specified in the Access Administrator Designation Form.	X_____________________________________
Access Administrator Signature	
Access Administrator Profile Information 		
Name: 	Check one box to either designate an individual as an Access Administrator or remove him/her if they no longer function as an Access Administrator.  	
Email Address: 		
Work Phone Number:  	  Designate*
  Remove	
Access Administrator’s Signature Required:
By signing this form, you agree to have read and accepted the terms and conditions applicable to Access Administrators as specified in the Access Administrator Designation Form.	X_____________________________________
Access Administrator Signature	
Access Administrator Profile Information 		
Name: 	Check one box to either designate an individual as an Access Administrator or remove him/her if they no longer function as an Access Administrator.  	
Email Address: 		
Work Phone Number:	 	  Designate*
  Remove	
Access Administrator’s Signature Required:
By signing this form, you agree to have read and accepted the terms and conditions applicable to Access Administrators as specified in the Access Administrator Designation Form.	X_____________________________________
Access Administrator Signature	
Entity/Organization Approval Signature 		

 X __________________________________	________________________________	  ___________________
	Authorized Representative Signature		Print Name 		Date	

As specified in the EOHHS Virtual Gateway Services Agreement entered into by and between the Commonwealth of Massachusetts, Executive Office of Health and Human Services (“EOHHS”) and the undersigned organizational entity (the “Entity”), the Entity hereby designates the individual identified on the corresponding Access Administrator Designation Form to act as the Entity’s Access Administrator (s).   
The Access Administrator must be a member of the Entity’s staff in the direct control of the Entity.  The Access Administrator shall be responsible for communicating to the EOHHS Virtual Gateway Administrator the identity of the individual end users (including employees, contractors, agents and Business Associates) authorized to access EOHHS Virtual Gateway Services on Entity’s behalf (each, an “End User” and collectively, the “End Users”).  The Access Administrator shall: (1) provide EOHHS with such information as it may require for each End User; (2) ensure that all information submitted to EOHHS about each End User is current, accurate, and complete; (3) notify EOHHS promptly of any End User whose access rights must be terminated, for example when an End User leaves the employment of the Entity; and (4) take such actions as EOHHS may direct or require to ensure the security of the Virtual Gateway.  Upon receipt from the Access Administrator of all End User information required by this Agreement and any exhibits or amendments thereto, and any additional information that EOHHS may deem necessary to assign such access rights to End Users, the EOHHS Virtual Gateway Administrator shall assign individual account information and access instructions directly to each End User within 5-7 business days.  
Entity must notify EOHHS in writing of any change in its Access Administrator designation within 5-7 business days of the change.  The Entity must execute a new “Access Administrator Designation” form for each new Access Administrator.  EOHHS has the right to terminate the rights of any Access Administrator and to require the Entity to designate a new Access Administrator.  Notwithstanding authorization by an Access Administrator, EOHHS reserves the right to terminate any authorized user’s access to the Virtual Gateway at any time, with or without cause, without notice and without penalty.
Entity/Organization (to be completed by an authorized representative)

Entity Name (Legal Organization Name)

Doing Business As (DBA)

Entity (Legal Organization) FEIN or Tax ID#	
	
Authorized Representative Signature	
	
Authorized Representative Print Name	
	
Authorized  Representative Print Title

Date
	
Mail to:
EOHHS Virtual Gateway Operations – IDM Operations
100 Hancock Street, 5th Floor
Quincy, MA 02171