Request a RosettaHealth Account
Request a new Intake and Referral Portal account for an organization

Account Signup Information required to create a certificate which will digitally 'sign' Direct messages for an organization.

Organization

Organization Name*

Legal Assumed Name (DBA)

Address

NOTE: Please fill in the legal address for the organization requesting the accounts. These accounts require a digital certificate. The address is used to verify the business is legitimate and in good standing. Therefore, this address must match the address of record maintained by the appropriate state and local agencies.

Country*

Address 1*

Address 2

City*

State*

Postal Code*

Authorized Representative

NOTE: Please fill in the information for the person responsible for this account. This person will need to be proofed and accountable for the digital certificate using in signing messages. The Authorized Representative must be an employee of Health Care Organization (HCO) listed above.

First Name*

Last Name*

Phone Number*

Email*

Other Info

Requested Subdomain*

Do Not Provide Security Email*

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