Accessing EIM/ESM

In order to begin using EIM/ESM, contracted providers must complete, sign, and return several forms. These forms are located below.
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New Virtual Gateway Providers:

New Virtual Gateway Provider going live with contracts on EIM/ESM for the first time will be required to complete the following forms:

Virtual Gateway Services Agreement

Access Administrator Designation Form

EIM/ESM Rider

EIM/ESM User Request Form

Organization Management Template

 

Existing Virtual Gateway Providers:

Existing Virtual Gateway providers going live with new contracts on EIM/ESM for the first time will be required to complete the following forms:

Access Administrator Designation Form (only if you wish to change existing Access Administrators or add new individuals)

EIM/ESM Rider

EIM/ESM User Request Form

File Transfer Service HIPAA User Request Form

Organization Management Template - Form D

 

 

Please note:

The Virtual Gateway Services Agreement, Access Administrator Designation Form and the EIM Rider are legal documents and must be signed by a legal signing authority within your organization and the original documents mailed to the address on the form.

The EIM/ESM User request form and Organization Management Template should be completed by an Access Administrator and e-mailed to the e-mail address on the form as an Excel document.

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