www.changehealthcare.com
Open in
urlscan Pro
151.101.195.10
Public Scan
Submitted URL: http://links.changehealthcare.mkt9570.com/els/v2/WNpktZLr8pfx/dThwVUZUUlJQYUZadlVPYnN0UE95Wmp2UTJPVVI3SSsrL1F1UlBhdjl4ODQ3VTR5TkdQS3hoLzZT...
Effective URL: https://www.changehealthcare.com/terms-of-use
Submission: On September 21 via api from US — Scanned from DE
Effective URL: https://www.changehealthcare.com/terms-of-use
Submission: On September 21 via api from US — Scanned from DE
Form analysis 3 forms found in the DOM
Name: ContactUs — POST https://tracking.changehealthcare.com/e/f2
<form method="post" name="ContactUs" action="https://tracking.changehealthcare.com/e/f2" onsubmit="return handleFormSubmit(this)" id="form419" class="elq-form" novalidate="novalidate">
<input value="ContactUs" type="hidden" name="elqFormName">
<input value="1647363395" type="hidden" name="elqSiteId">
<input name="elqCampaignId" type="hidden">
<span id="action_insert_16589433837748615" class="at-element-marker" style="top: -15px !important; position: relative !important;"><span style="color:#001f3f;">Interested in learning more about how our solutions can help? Fill out the form below
and an expert will reach out shortly to discuss your needs. If you're looking for product support, you can access your
</span><a href="https://support.changehealthcare.com/customer-support-portals" target="_self"><span style="color:#b10dc9;">support portal here</span></a><span style="color:#001f3f;">.</span></span>
<div id="formElement0" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size at-element-marker">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field0" class="label-position top ">First Name <span class="required">* </span>
</label>
<input id="field0" name="firstName" type="text" value="" class="field-size-top-medium" required="">
</p>
</div>
</div>
</div>
<div id="formElement1" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field1" class="label-position top ">Last Name <span class="required">* </span>
</label>
<input id="field1" name="lastName" type="text" value="" class="field-size-top-medium" required="">
</p>
</div>
</div>
</div>
<div id="formElement2" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size full-width">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field2" class="label-position top ">Business Email: <span class="required">* </span>
</label>
<input id="field2" name="emailAddress" type="email" value="" class="field-size-top-medium" required="">
</p>
</div>
</div>
</div>
<div id="formElement3" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field3" class="label-position top ">Job Function <span class="required">* </span>
</label>
<select id="field3" name="jobRole1" data-value="<eloqua type='emailfield' syntax='Job_Function1' />" class="field-size-top-medium" required="">
<option value="">-- Please Select -- </option>
<option value="Administrative/Human Resources">Administrative/Human Resources </option>
<option value="Administrator">Administrator </option>
<option value="Billing/Coding">Billing/Coding </option>
<option value="Board Member/Director/Trustee">Board Member/Director/Trustee </option>
<option value="Cardiology">Cardiology </option>
<option value="Care Management/Population Health">Care Management/Population Health </option>
<option value="Claims & Denials">Claims & Denials </option>
<option value="Consulting">Consulting </option>
<option value="Dentistry">Dentistry </option>
<option value="EDI">EDI </option>
<option value="EHR Implementation/Management">EHR Implementation/Management </option>
<option value="Engineering/Technical Staff">Engineering/Technical Staff </option>
<option value="Enrollment">Enrollment </option>
<option value="Executive">Executive </option>
<option value="Finance/Accounting">Finance/Accounting </option>
<option value="General Management">General Management </option>
<option value="Information Systems/Technology">Information Systems/Technology </option>
<option value="Laboratory">Laboratory </option>
<option value="Legal/Regulatory/Compliance">Legal/Regulatory/Compliance </option>
<option value="Medical Auditing">Medical Auditing </option>
<option value="Medical Practice Management">Medical Practice Management </option>
<option value="Member Engagement">Member Engagement </option>
<option value="Nurse/Nursing Executive">Nurse/Nursing Executive </option>
<option value="Office Manager">Office Manager </option>
<option value="Operations">Operations </option>
<option value="Patient Access">Patient Access </option>
<option value="Patient Financial Services">Patient Financial Services </option>
<option value="Pharmacy">Pharmacy </option>
<option value="Physician">Physician </option>
<option value="Physician Practice Management">Physician Practice Management </option>
<option value="Procurement/Purchasing/Supply">Procurement/Purchasing/Supply </option>
<option value="Project Management">Project Management </option>
<option value="Radiology">Radiology </option>
<option value="Revenue Cycle Management">Revenue Cycle Management </option>
<option value="Sales/Business Development/Marketing">Sales/Business Development/Marketing </option>
<option value="Training/Education">Training/Education </option>
<option value="Vendor Relationships">Vendor Relationships </option>
<option value="Other">Other </option>
</select>
</p>
</div>
</div>
</div>
<div id="formElement4" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field4" class="label-position top ">Job Level <span class="required">* </span>
</label>
<select id="field4" name="jobLevel1" data-value="<eloqua type='emailfield' syntax='Job_Lebel1' />" class="field-size-top-medium" required="">
<option value="">-- Please Select -- </option>
<option value="Analyst/Administrator">Analyst/Administrator </option>
<option value="Chief Compliance Officer">Chief Compliance Officer </option>
<option value="Chief Executive Officer">Chief Executive Officer </option>
<option value="Chief Financial Officer">Chief Financial Officer </option>
<option value="Chief Information Officer">Chief Information Officer </option>
<option value="Chief Medical Information Officer">Chief Medical Information Officer </option>
<option value="Chief Medical Officer">Chief Medical Officer </option>
<option value="Chief Operating Officer">Chief Operating Officer </option>
<option value="Chief Quality Officer">Chief Quality Officer </option>
<option value="Chief Technology Officer">Chief Technology Officer </option>
<option value="C-Level">C-Level </option>
<option value="Department Chair">Department Chair </option>
<option value="Director">Director </option>
<option value="Doctor">Doctor </option>
<option value="Individual Contributor">Individual Contributor </option>
<option value="Manager">Manager </option>
<option value="President">President </option>
<option value="Senior Vice President">Senior Vice President </option>
<option value="Vice President">Vice President </option>
<option value="Other">Other </option>
</select>
</p>
</div>
</div>
</div>
<div id="formElement5" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<!-- SOI update Feb11 START -->
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field5" class="label-position top ">Solution of Interest <span class="required">* </span>
</label>
<select id="field5" name="productSolutionOfInterest1" class="field-size-top-medium" required="">
<option value="" selected="selected">-- Please Select -- </option>
<option value="Decision Support">Clinical Decision Support Solutions </option>
<option value="Clinical Network">Clinical Interoperability Solutions </option>
<option value="Consumer Payments & Communications">Consumer Payments & Communications </option>
<option value="Dental EDI Network">Dental Network Solutions </option>
<option value="Imaging">Enterprise Imaging Solutions </option>
<option value="Consulting">Healthcare Consulting Services </option>
<option value="Data & Analytics">Healthcare Data & Analytics Solutions </option>
<option value="Medical Network">Medical Network Solutions </option>
<option value="Medical Record Retrieval & Clinical Review
">Medical Record Retrieval & Clinical Review </option>
<option value="Eligibility & Enrollment">Member Eligibility & Enrollment Solutions </option>
<option value="Member Engagement">Member Engagement Solutions </option>
<option value="Patient Access & Eligibility">Patient Access & Financial Clearance Solutions </option>
<option value="Engagement & Experience">Engagement & Experience </option>
<option value="Connected Consumer Health - Provider">Patient Experience Solutions </option>
<option value="Payment Accuracy">Payment Accuracy Solutions </option>
<option value="Pharmacy Benefit Solutions">Pharmacy Benefit Solutions </option>
<option value="Pharmacy Solutions">Pharmacy Solutions </option>
<option value="Provider Network Optimization">Provider Network Optimization Solutions </option>
<option value="Provider Payments">Provider Payment Management Solutions </option>
<option value="Revenue Improvement">Revenue Cycle Management Solutions </option>
<option value="Risk Adjustment Analytics">Risk Adjustment and Quality Solutions </option>
<option value="Transparency & Provider Search">Transparency & Provider Search </option>
<option value="Value-Based Care Enablement">Value-Based Care Enablement </option>
<option value="Value-Based Payments">Value-Based Care Solutions </option>
</select>
</p>
</div>
</div>
</div>
<!-- SOI update Feb11 END -->
<div id="formElement6" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size" style="display: none;">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field6" class="label-position top ">Solution Type </label>
<select id="field6" name="solutionType1" class="field-size-top-medium">
<option value="">-- Please Select -- </option>
<option value="Services">Services </option>
<option value="Technology">Technology </option>
<option value="Unsure">Unsure </option>
</select>
</p>
</div>
</div>
</div>
<div id="formElement7" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size" style="display: none;">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field7" class="label-position top ">Claims Volume </label>
<input id="field7" name="ClaimsVolume" type="text" value="" class="field-size-top-medium">
</p>
</div>
</div>
</div>
<div id="formElement8" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field8" class="label-position top ">Company <span class="required">* </span>
</label>
<input id="field8" name="company" type="text" value="" class="field-size-top-medium" required="">
</p>
</div>
</div>
</div>
<div id="formElement9" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field9" class="label-position top ">Company Type <span class="required">* </span>
</label>
<select id="field9" name="organizationType1" data-value="<eloqua type='emailfield' syntax='Company_Type1' />" class="field-size-top-medium" required="">
<option value="" selected="selected">-- Please Select -- </option>
<option value="Billing Service">Billing Service </option>
<option value="Dental">Dental </option>
<option value="Emergency Medical Service">Emergency Medical Service </option>
<option value="Government Agency">Government Agency </option>
<option value="Healthcare Information Exchange">Healthcare Information Exchange </option>
<option value="Home Health Agency">Home Health Agency </option>
<option value="Hospital Employed Practice">Hospital Employed Practice </option>
<option value="Hospital/Health System">Hospital/Health System </option>
<option value="Imaging Center">Imaging Center </option>
<option value="Independent Practice Affiliated with Hospital">Independent Practice Affiliated with Hospital </option>
<option value="Independent Practice Not Affiliated with Hospital">Independent Practice Not Affiliated with Hospital </option>
<option value="Laboratory">Laboratory </option>
<option value="Partner/Reseller">Partner/Reseller </option>
<option value="Payer">Payer </option>
<option value="Software Vendor">Software Vendor </option>
<option value="Trust">Trust </option>
<option value="Other">Other </option>
</select>
</p>
</div>
</div>
</div>
<div id="formElement10" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size" style="display: none;">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field10" class="label-position top ">Bed Size </label>
<select id="field10" name="BedSize" class="field-size-top-medium">
<option value="" selected="selected">-- Please Select -- </option>
<option value="1-199">1-199 </option>
<option value="200+">200+ </option>
</select>
</p>
</div>
</div>
</div>
<div id="formElement11" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size" style="display: none;">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field11" class="label-position top ">Practice Specialty </label>
<select id="field11" name="ProviderSpecialty" class="field-size-top-medium">
<option value="">-- Please Select -- </option>
<option value="Anesthesia">Anesthesia </option>
<option value="Cardiology">Cardiology </option>
<option value="Emergency Medicine">Emergency Medicine </option>
<option value="Pathology">Pathology </option>
<option value="Radiology">Radiology </option>
<option value="Other">Other </option>
</select>
</p>
</div>
</div>
</div>
<div id="formElement12" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size" style="display: none;">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field12" class="label-position top ">Number of Covered Lives </label>
<input id="field12" name="NumCoveredLives" type="text" value="" class="field-size-top-medium">
</p>
</div>
</div>
</div>
<div id="formElement13" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size" style="display: none;">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field13" class="label-position top ">Practice Management Software Vendor </label>
<input id="field13" name="SoftwareVendor" type="text" value="" class="field-size-top-medium">
</p>
</div>
</div>
</div>
<div id="formElement14" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field14" class="label-position top ">Business Phone <span class="required">* </span>
</label>
<input id="field14" name="busPhone" type="text" value="" class="field-size-top-medium" required="">
</p>
</div>
</div>
</div>
<div id="formElement15" class="sc-view form-design-field sc-static-layout item-padding sc-regular-size">
<div class="field-wrapper">
</div>
<div class="individual field-wrapper">
<div class="_100 field-style">
<p class="field-p">
<label for="field15" class="label-position top ">Country <span class="required">* </span>
</label>
<select id="field15" name="Country" class="field-size-top-medium" required="">
<option value="">Please select </option>
<option value="US">United States </option>
<option value="GB">United Kingdom </option>
<option value="CA">Canada </option>
<option value="IN">India </option>
<option value="NL">Netherlands </option>
<option value="AU">Australia </option>
<option value="ZA">South Africa </option>
<option value="FR">France </option>
<option value="DE">Germany </option>
<option value="SG">Singapore </option>
<option value="SE">Sweden </option>
<option value="BR">Brazil </option>
<option value="">-------------- </option>
<option value="AF">Afghanistan </option>
<option value="AX">Åland Islands </option>
<option value="AL">Albania </option>
<option value="DZ">Algeria </option>
<option value="AS">American Samoa </option>
<option value="AD">Andorra </option>
<option value="AO">Angola </option>
<option value="AI">Anguilla </option>
<option value="AQ">Antarctica </option>
<option value="AG">Antigua and Barbuda </option>
<option value="AR">Argentina </option>
<option value="AM">Armenia </option>
<option value="AW">Aruba </option>
<option value="AU">Australia </option>
<option value="AT">Austria </option>
<option value="AZ">Azerbaijan </option>
<option value="BS">Bahamas </option>
<option value="BH">Bahrain </option>
<option value="BD">Bangladesh </option>
<option value="BB">Barbados </option>
<option value="BY">Belarus </option>
<option value="BE">Belgium </option>
<option value="BZ">Belize </option>
<option value="BJ">Benin </option>
<option value="BM">Bermuda </option>
<option value="BT">Bhutan </option>
<option value="BO">Bolivia </option>
<option value="BA">Bosnia and Herzegovina </option>
<option value="BW">Botswana </option>
<option value="BV">Bouvet Island </option>
<option value="BR">Brazil </option>
<option value="IO">Brit/Indian Ocean Terr. </option>
<option value="BN">Brunei Darussalam </option>
<option value="BG">Bulgaria </option>
<option value="BF">Burkina Faso </option>
<option value="BI">Burundi </option>
<option value="KH">Cambodia </option>
<option value="CM">Cameroon </option>
<option value="CA">Canada </option>
<option value="CV">Cape Verde </option>
<option value="KY">Cayman Islands </option>
<option value="CF">Central African Republic </option>
<option value="TD">Chad </option>
<option value="CL">Chile </option>
<option value="CN">China </option>
<option value="CX">Christmas Island </option>
<option value="CC">Cocos (Keeling) Islands </option>
<option value="CO">Colombia </option>
<option value="KM">Comoros </option>
<option value="CG">Congo </option>
<option value="CD">Congo, The Dem. Republic Of </option>
<option value="CK">Cook Islands </option>
<option value="CR">Costa Rica </option>
<option value="CI">Côte d'Ivoire </option>
<option value="HR">Croatia </option>
<option value="CU">Cuba </option>
<option value="CY">Cyprus </option>
<option value="CZ">Czech Republic </option>
<option value="DK">Denmark </option>
<option value="DJ">Djibouti </option>
<option value="DM">Dominica </option>
<option value="DO">Dominican Republic </option>
<option value="EC">Ecuador </option>
<option value="EG">Egypt </option>
<option value="SV">El Salvador </option>
<option value="GQ">Equatorial Guinea </option>
<option value="ER">Eritrea </option>
<option value="EE">Estonia </option>
<option value="ET">Ethiopia </option>
<option value="FK">Falkland Islands </option>
<option value="FO">Faroe Islands </option>
<option value="FJ">Fiji </option>
<option value="FI">Finland </option>
<option value="FR">France </option>
<option value="GF">French Guiana </option>
<option value="PF">French Polynesia </option>
<option value="TF">French Southern Terr. </option>
<option value="GA">Gabon </option>
<option value="GM">Gambia </option>
<option value="GE">Georgia </option>
<option value="DE">Germany </option>
<option value="GH">Ghana </option>
<option value="GI">Gibraltar </option>
<option value="GB">United Kingdom </option>
<option value="GR">Greece </option>
<option value="GL">Greenland </option>
<option value="GD">Grenada </option>
<option value="GP">Guadeloupe </option>
<option value="GU">Guam </option>
<option value="GT">Guatemala </option>
<option value="GN">Guinea </option>
<option value="GW">Guinea-Bissau </option>
<option value="GY">Guyana </option>
<option value="HT">Haiti </option>
<option value="HM">Heard/McDonald Isls. </option>
<option value="HN">Honduras </option>
<option value="HK">Hong Kong </option>
<option value="HU">Hungary </option>
<option value="IS">Iceland </option>
<option value="IN">India </option>
<option value="ID">Indonesia </option>
<option value="IR">Iran </option>
<option value="IQ">Iraq </option>
<option value="IE">Ireland </option>
<option value="IL">Israel </option>
<option value="IT">Italy </option>
<option value="JM">Jamaica </option>
<option value="JP">Japan </option>
<option value="JO">Jordan </option>
<option value="KZ">Kazakhstan </option>
<option value="KE">Kenya </option>
<option value="KI">Kiribati </option>
<option value="KP">Korea (North) </option>
<option value="KR">Korea (South) </option>
<option value="KW">Kuwait </option>
<option value="KG">Kyrgyzstan </option>
<option value="LA">Laos </option>
<option value="LV">Latvia </option>
<option value="LB">Lebanon </option>
<option value="LS">Lesotho </option>
<option value="LR">Liberia </option>
<option value="LY">Libya </option>
<option value="LI">Liechtenstein </option>
<option value="LT">Lithuania </option>
<option value="LU">Luxembourg </option>
<option value="MO">Macau </option>
<option value="MK">Macedonia </option>
<option value="MG">Madagascar </option>
<option value="MW">Malawi </option>
<option value="MY">Malaysia </option>
<option value="MV">Maldives </option>
<option value="ML">Mali </option>
<option value="MT">Malta </option>
<option value="MH">Marshall Islands </option>
<option value="MQ">Martinique </option>
<option value="MR">Mauritania </option>
<option value="MU">Mauritius </option>
<option value="YT">Mayotte </option>
<option value="MX">Mexico </option>
<option value="FM">Micronesia </option>
<option value="MD">Moldova </option>
<option value="MC">Monaco </option>
<option value="MN">Mongolia </option>
<option value="MS">Montserrat </option>
<option value="MA">Morocco </option>
<option value="MZ">Mozambique </option>
<option value="MM">Myanmar </option>
<option value="MP">N. Mariana Isls. </option>
<option value="NA">Namibia </option>
<option value="NR">Nauru </option>
<option value="NP">Nepal </option>
<option value="NL">Netherlands </option>
<option value="AN">Netherlands Antilles </option>
<option value="NC">New Caledonia </option>
<option value="NZ">New Zealand </option>
<option value="NI">Nicaragua </option>
<option value="NE">Niger </option>
<option value="NG">Nigeria </option>
<option value="NU">Niue </option>
<option value="NF">Norfolk Island </option>
<option value="NO">Norway </option>
<option value="OM">Oman </option>
<option value="PK">Pakistan </option>
<option value="PW">Palau </option>
<option value="PS">Palestinian Territory, Occupied </option>
<option value="PA">Panama </option>
<option value="PG">Papua New Guinea </option>
<option value="PY">Paraguay </option>
<option value="PE">Peru </option>
<option value="PH">Philippines </option>
<option value="PN">Pitcairn </option>
<option value="PL">Poland </option>
<option value="PT">Portugal </option>
<option value="PR">Puerto Rico </option>
<option value="QA">Qatar </option>
<option value="RE">Reunion </option>
<option value="RO">Romania </option>
<option value="RU">Russian Federation </option>
<option value="RW">Rwanda </option>
<option value="KN">Saint Kitts and Nevis </option>
<option value="LC">Saint Lucia </option>
<option value="WS">Samoa </option>
<option value="SM">San Marino </option>
<option value="ST">Sao Tome/Principe </option>
<option value="SA">Saudi Arabia </option>
<option value="SN">Senegal </option>
<option value="CS">Serbia and Montenegro </option>
<option value="SC">Seychelles </option>
<option value="SL">Sierra Leone </option>
<option value="SG">Singapore </option>
<option value="SK">Slovak Republic </option>
<option value="SI">Slovenia </option>
<option value="SB">Solomon Islands </option>
<option value="SO">Somalia </option>
<option value="ZA">South Africa </option>
<option value="ES">Spain </option>
<option value="LK">Sri Lanka </option>
<option value="SH">St. Helena </option>
<option value="PM">St. Pierre and Miquelon </option>
<option value="VC">St. Vincent and Grenadines </option>
<option value="SD">Sudan </option>
<option value="SR">Suriname </option>
<option value="SJ">Svalbard/Jan Mayen Isls. </option>
<option value="SZ">Swaziland </option>
<option value="SE">Sweden </option>
<option value="CH">Switzerland </option>
<option value="SY">Syria </option>
<option value="TW">Taiwan </option>
<option value="TJ">Tajikistan </option>
<option value="TZ">Tanzania </option>
<option value="TH">Thailand </option>
<option value="TL">Timor-Leste </option>
<option value="TG">Togo </option>
<option value="TK">Tokelau </option>
<option value="TO">Tonga </option>
<option value="TT">Trinidad and Tobago </option>
<option value="TN">Tunisia </option>
<option value="TR">Turkey </option>
<option value="TM">Turkmenistan </option>
<option value="TC">Turks/Caicos Isls. </option>
<option value="TV">Tuvalu </option>
<option value="UG">Uganda </option>
<option value="UA">Ukraine </option>
<option value="AE">United Arab Emirates </option>
<option value="US">United States </option>
<option value="UM">US Minor Outlying Is. </option>
<option value="UY">Uruguay </option>
<option value="UZ">Uzbekistan </option>
<option value="VU">Vanuatu </option>
<option value="VA">Vatican City </option>
<option value="VE">Venezuela </option>
<option value="VN">Viet Nam </option>
<option value="VG">Virgin Islands (British) </option>
<option value="VI">Virgin Islands (U.S.) </option>
<option value="WF">Wallis/Futuna Isls. </option>
<option value="EH">Western Sahara </option>
<option value="YE">Yemen </option>
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<option value="ZW">Zimbabwe </option>
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<option value="AS">American Samoa </option>
<option value="AZ">Arizona </option>
<option value="CA">California </option>
<option value="CO">Colorado </option>
<option value="CT">Connecticut </option>
<option value="DC">D.C. </option>
<option value="DE">Delaware </option>
<option value="FL">Florida </option>
<option value="FM">Micronesia </option>
<option value="GA">Georgia </option>
<option value="GU">Guam </option>
<option value="HI">Hawaii </option>
<option value="IA">Iowa </option>
<option value="ID">Idaho </option>
<option value="IL">Illinois </option>
<option value="IN">Indiana </option>
<option value="KS">Kansas </option>
<option value="KY">Kentucky </option>
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<option value="MD">Maryland </option>
<option value="ME">Maine </option>
<option value="MH">Marshall Islands </option>
<option value="MI">Michigan </option>
<option value="MN">Minnesota </option>
<option value="MO">Missouri </option>
<option value="MP">Marianas </option>
<option value="MS">Mississippi </option>
<option value="MT">Montana </option>
<option value="NC">North Carolina </option>
<option value="ND">North Dakota </option>
<option value="NE">Nebraska </option>
<option value="NH">New Hampshire </option>
<option value="NJ">New Jersey </option>
<option value="NM">New Mexico </option>
<option value="NV">Nevada </option>
<option value="NY">New York </option>
<option value="OH">Ohio </option>
<option value="OK">Oklahoma </option>
<option value="OR">Oregon </option>
<option value="PA">Pennsylvania </option>
<option value="PR">Puerto Rico </option>
<option value="PW">Palau </option>
<option value="RI">Rhode Island </option>
<option value="SC">South Carolina </option>
<option value="SD">South Dakota </option>
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<option value="TX">Texas </option>
<option value="UT">Utah </option>
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<option value="VI">Virgin Islands </option>
<option value="VT">Vermont </option>
<option value="WA">Washington </option>
<option value="WI">Wisconsin </option>
<option value="WV">West Virginia </option>
<option value="WY">Wyoming </option>
<option value="">-- Other Locations -- </option>
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<option value="AP">Military Pacific </option>
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<option value="NT">Northwest Territories </option>
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<option value="ON">Ontario </option>
<option value="PE">Prince Edward Island </option>
<option value="QC">Quebec </option>
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<option value="">-------------- </option>
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<option value="BY">Belarus </option>
<option value="BE">Belgium </option>
<option value="BZ">Belize </option>
<option value="BJ">Benin </option>
<option value="BM">Bermuda </option>
<option value="BT">Bhutan </option>
<option value="BO">Bolivia </option>
<option value="BA">Bosnia and Herzegovina </option>
<option value="BW">Botswana </option>
<option value="BV">Bouvet Island </option>
<option value="BR">Brazil </option>
<option value="IO">Brit/Indian Ocean Terr. </option>
<option value="BN">Brunei Darussalam </option>
<option value="BG">Bulgaria </option>
<option value="BF">Burkina Faso </option>
<option value="BI">Burundi </option>
<option value="KH">Cambodia </option>
<option value="CM">Cameroon </option>
<option value="CA">Canada </option>
<option value="CV">Cape Verde </option>
<option value="KY">Cayman Islands </option>
<option value="CF">Central African Republic </option>
<option value="TD">Chad </option>
<option value="CL">Chile </option>
<option value="CN">China </option>
<option value="CX">Christmas Island </option>
<option value="CC">Cocos (Keeling) Islands </option>
<option value="CO">Colombia </option>
<option value="KM">Comoros </option>
<option value="CG">Congo </option>
<option value="CD">Congo, The Dem. Republic Of </option>
<option value="CK">Cook Islands </option>
<option value="CR">Costa Rica </option>
<option value="CI">Côte d'Ivoire </option>
<option value="HR">Croatia </option>
<option value="CU">Cuba </option>
<option value="CY">Cyprus </option>
<option value="CZ">Czech Republic </option>
<option value="DK">Denmark </option>
<option value="DJ">Djibouti </option>
<option value="DM">Dominica </option>
<option value="DO">Dominican Republic </option>
<option value="EC">Ecuador </option>
<option value="EG">Egypt </option>
<option value="SV">El Salvador </option>
<option value="GQ">Equatorial Guinea </option>
<option value="ER">Eritrea </option>
<option value="EE">Estonia </option>
<option value="ET">Ethiopia </option>
<option value="FK">Falkland Islands </option>
<option value="FO">Faroe Islands </option>
<option value="FJ">Fiji </option>
<option value="FI">Finland </option>
<option value="FR">France </option>
<option value="GF">French Guiana </option>
<option value="PF">French Polynesia </option>
<option value="TF">French Southern Terr. </option>
<option value="GA">Gabon </option>
<option value="GM">Gambia </option>
<option value="GE">Georgia </option>
<option value="DE">Germany </option>
<option value="GH">Ghana </option>
<option value="GI">Gibraltar </option>
<option value="GB">United Kingdom </option>
<option value="GR">Greece </option>
<option value="GL">Greenland </option>
<option value="GD">Grenada </option>
<option value="GP">Guadeloupe </option>
<option value="GU">Guam </option>
<option value="GT">Guatemala </option>
<option value="GN">Guinea </option>
<option value="GW">Guinea-Bissau </option>
<option value="GY">Guyana </option>
<option value="HT">Haiti </option>
<option value="HM">Heard/McDonald Isls. </option>
<option value="HN">Honduras </option>
<option value="HK">Hong Kong </option>
<option value="HU">Hungary </option>
<option value="IS">Iceland </option>
<option value="IN">India </option>
<option value="ID">Indonesia </option>
<option value="IR">Iran </option>
<option value="IQ">Iraq </option>
<option value="IE">Ireland </option>
<option value="IL">Israel </option>
<option value="IT">Italy </option>
<option value="JM">Jamaica </option>
<option value="JP">Japan </option>
<option value="JO">Jordan </option>
<option value="KZ">Kazakhstan </option>
<option value="KE">Kenya </option>
<option value="KI">Kiribati </option>
<option value="KP">Korea (North) </option>
<option value="KR">Korea (South) </option>
<option value="KW">Kuwait </option>
<option value="KG">Kyrgyzstan </option>
<option value="LA">Laos </option>
<option value="LV">Latvia </option>
<option value="LB">Lebanon </option>
<option value="LS">Lesotho </option>
<option value="LR">Liberia </option>
<option value="LY">Libya </option>
<option value="LI">Liechtenstein </option>
<option value="LT">Lithuania </option>
<option value="LU">Luxembourg </option>
<option value="MO">Macau </option>
<option value="MK">Macedonia </option>
<option value="MG">Madagascar </option>
<option value="MW">Malawi </option>
<option value="MY">Malaysia </option>
<option value="MV">Maldives </option>
<option value="ML">Mali </option>
<option value="MT">Malta </option>
<option value="MH">Marshall Islands </option>
<option value="MQ">Martinique </option>
<option value="MR">Mauritania </option>
<option value="MU">Mauritius </option>
<option value="YT">Mayotte </option>
<option value="MX">Mexico </option>
<option value="FM">Micronesia </option>
<option value="MD">Moldova </option>
<option value="MC">Monaco </option>
<option value="MN">Mongolia </option>
<option value="MS">Montserrat </option>
<option value="MA">Morocco </option>
<option value="MZ">Mozambique </option>
<option value="MM">Myanmar </option>
<option value="MP">N. Mariana Isls. </option>
<option value="NA">Namibia </option>
<option value="NR">Nauru </option>
<option value="NP">Nepal </option>
<option value="NL">Netherlands </option>
<option value="AN">Netherlands Antilles </option>
<option value="NC">New Caledonia </option>
<option value="NZ">New Zealand </option>
<option value="NI">Nicaragua </option>
<option value="NE">Niger </option>
<option value="NG">Nigeria </option>
<option value="NU">Niue </option>
<option value="NF">Norfolk Island </option>
<option value="NO">Norway </option>
<option value="OM">Oman </option>
<option value="PK">Pakistan </option>
<option value="PW">Palau </option>
<option value="PS">Palestinian Territory, Occupied </option>
<option value="PA">Panama </option>
<option value="PG">Papua New Guinea </option>
<option value="PY">Paraguay </option>
<option value="PE">Peru </option>
<option value="PH">Philippines </option>
<option value="PN">Pitcairn </option>
<option value="PL">Poland </option>
<option value="PT">Portugal </option>
<option value="PR">Puerto Rico </option>
<option value="QA">Qatar </option>
<option value="RE">Reunion </option>
<option value="RO">Romania </option>
<option value="RU">Russian Federation </option>
<option value="RW">Rwanda </option>
<option value="KN">Saint Kitts and Nevis </option>
<option value="LC">Saint Lucia </option>
<option value="WS">Samoa </option>
<option value="SM">San Marino </option>
<option value="ST">Sao Tome/Principe </option>
<option value="SA">Saudi Arabia </option>
<option value="SN">Senegal </option>
<option value="CS">Serbia and Montenegro </option>
<option value="SC">Seychelles </option>
<option value="SL">Sierra Leone </option>
<option value="SG">Singapore </option>
<option value="SK">Slovak Republic </option>
<option value="SI">Slovenia </option>
<option value="SB">Solomon Islands </option>
<option value="SO">Somalia </option>
<option value="ZA">South Africa </option>
<option value="ES">Spain </option>
<option value="LK">Sri Lanka </option>
<option value="SH">St. Helena </option>
<option value="PM">St. Pierre and Miquelon </option>
<option value="VC">St. Vincent and Grenadines </option>
<option value="SD">Sudan </option>
<option value="SR">Suriname </option>
<option value="SJ">Svalbard/Jan Mayen Isls. </option>
<option value="SZ">Swaziland </option>
<option value="SE">Sweden </option>
<option value="CH">Switzerland </option>
<option value="SY">Syria </option>
<option value="TW">Taiwan </option>
<option value="TJ">Tajikistan </option>
<option value="TZ">Tanzania </option>
<option value="TH">Thailand </option>
<option value="TL">Timor-Leste </option>
<option value="TG">Togo </option>
<option value="TK">Tokelau </option>
<option value="TO">Tonga </option>
<option value="TT">Trinidad and Tobago </option>
<option value="TN">Tunisia </option>
<option value="TR">Turkey </option>
<option value="TM">Turkmenistan </option>
<option value="TC">Turks/Caicos Isls. </option>
<option value="TV">Tuvalu </option>
<option value="UG">Uganda </option>
<option value="UA">Ukraine </option>
<option value="AE">United Arab Emirates </option>
<option value="US">United States </option>
<option value="UM">US Minor Outlying Is. </option>
<option value="UY">Uruguay </option>
<option value="UZ">Uzbekistan </option>
<option value="VU">Vanuatu </option>
<option value="VA">Vatican City </option>
<option value="VE">Venezuela </option>
<option value="VN">Viet Nam </option>
<option value="VG">Virgin Islands (British) </option>
<option value="VI">Virgin Islands (U.S.) </option>
<option value="WF">Wallis/Futuna Isls. </option>
<option value="EH">Western Sahara </option>
<option value="YE">Yemen </option>
<option value="ZM">Zambia </option>
<option value="ZW">Zimbabwe </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement6" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45577">State or Province <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45577" name="stateProv" style="width:100%;" data-value="~~eloqua..type--emailfield..syntax--State_Prov~~" required="">
<option value="">Please Select... </option>
<option value="AK">Alaska </option>
<option value="AL">Alabama </option>
<option value="AR">Arkansas </option>
<option value="AS">American Samoa </option>
<option value="AZ">Arizona </option>
<option value="CA">California </option>
<option value="CO">Colorado </option>
<option value="CT">Connecticut </option>
<option value="DC">D.C. </option>
<option value="DE">Delaware </option>
<option value="FL">Florida </option>
<option value="FM">Micronesia </option>
<option value="GA">Georgia </option>
<option value="GU">Guam </option>
<option value="HI">Hawaii </option>
<option value="IA">Iowa </option>
<option value="ID">Idaho </option>
<option value="IL">Illinois </option>
<option value="IN">Indiana </option>
<option value="KS">Kansas </option>
<option value="KY">Kentucky </option>
<option value="LA">Louisiana </option>
<option value="MA">Massachusetts </option>
<option value="MD">Maryland </option>
<option value="ME">Maine </option>
<option value="MH">Marshall Islands </option>
<option value="MI">Michigan </option>
<option value="MN">Minnesota </option>
<option value="MO">Missouri </option>
<option value="MP">Marianas </option>
<option value="MS">Mississippi </option>
<option value="MT">Montana </option>
<option value="NC">North Carolina </option>
<option value="ND">North Dakota </option>
<option value="NE">Nebraska </option>
<option value="NH">New Hampshire </option>
<option value="NJ">New Jersey </option>
<option value="NM">New Mexico </option>
<option value="NV">Nevada </option>
<option value="NY">New York </option>
<option value="OH">Ohio </option>
<option value="OK">Oklahoma </option>
<option value="OR">Oregon </option>
<option value="PA">Pennsylvania </option>
<option value="PR">Puerto Rico </option>
<option value="PW">Palau </option>
<option value="RI">Rhode Island </option>
<option value="SC">South Carolina </option>
<option value="SD">South Dakota </option>
<option value="TN">Tennessee </option>
<option value="TX">Texas </option>
<option value="UT">Utah </option>
<option value="VA">Virginia </option>
<option value="VI">Virgin Islands </option>
<option value="VT">Vermont </option>
<option value="WA">Washington </option>
<option value="WI">Wisconsin </option>
<option value="WV">West Virginia </option>
<option value="WY">Wyoming </option>
<option value="">-- Other Locations -- </option>
<option value="AA">Military Americas </option>
<option value="AE">Military Europe/ME/Canada </option>
<option value="AP">Military Pacific </option>
<option value="AB">Alberta </option>
<option value="MB">Manitoba </option>
<option value="BC">British Columbia </option>
<option value="NB">New Brunswick </option>
<option value="NL">Newfoundland and Labrador </option>
<option value="NS">Nova Scotia </option>
<option value="NT">Northwest Territories </option>
<option value="NU">Nunavut </option>
<option value="ON">Ontario </option>
<option value="PE">Prince Edward Island </option>
<option value="QC">Quebec </option>
<option value="SK">Saskatchewan </option>
<option value="YT">Yukon Territory </option>
<option value="Other">Other </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement7" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45578">Address 1 <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input" name="address1" id="fe45578" value="" style="width:100%;" required="">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement8" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45579">Company Website </label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input" name="website" id="fe45579" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement9" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45580">Company Profile <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45580" name="companyProfile" style="width:100%;" data-value="" required="">
<option value="">Select </option>
<option value="Public">Public </option>
<option value="Partnership">Partnership </option>
<option value="Incorporated">Incorporated </option>
<option value="Start Up">Start Up </option>
<option value="Association">Association </option>
<option value="Other">Other </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement10" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45581">What best describes what you would like to learn more about? </label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45581" name="learnMore" style="width:100%;" data-value="">
<option value="">Select </option>
<option value="The overall Change Healthcare solution portfolio">The overall Change Healthcare solution portfolio </option>
<option value="A specific solution area">A specific solution area </option>
<option value="Partnership programs at Change Healthcare">Partnership programs at Change Healthcare </option>
<option value="How to become a Partner">How to become a Partner </option>
<option value="Other">Other </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement11" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45582">What type of products or services does your company provide? </label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45582" name="productsServices" style="width:100%;" data-value="">
<option value="">Select </option>
<option value="Clinical Solutions">Clinical Solutions </option>
<option value="Rev Cycle Solutions">Rev Cycle Solutions </option>
<option value="Ambulatory Solutions (non-acute)">Ambulatory Solutions (non-acute) </option>
<option value="Connectivity/Integration Solutions">Connectivity/Integration Solutions </option>
<option value="Data Solutions">Data Solutions </option>
<option value="Services (Managed, Implementation, Consulting, Education, Hosting, etc)">Services (Managed, Implementation, Consulting, Education, Hosting, etc) </option>
<option value="Technical">Technical </option>
<option value="EMR/EHR">EMR/EHR </option>
<option value="Digital Health">Digital Health </option>
<option value="Platform">Platform </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement12" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45583">Type of partnership interest? <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45583" name="typePartnership" style="width:100%;" data-value="" required="">
<option value="">Select </option>
<option value="API marketplace">API marketplace </option>
<option value="Channel">Channel </option>
<option value="Data subscription">Data subscription </option>
<option value="Technology">Technology </option>
<option value="Vendor">Vendor </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement13" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45584">How would you describe the opportunity for partnership between our two organizations? </label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<textarea class="elq-item-textarea" style="width:100%;" name="partnershipOppt" id="fe45584"> </textarea>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement14" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45585">Who are the targeted end users? <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45585" name="targetUsers" style="width:100%;" data-value="" required="">
<option value="">Select </option>
<option value="Hospitals/health systems">Hospitals/health systems </option>
<option value="Dental">Dental </option>
<option value="Physicians">Physicians </option>
<option value="Nurses">Nurses </option>
<option value="Physician practices">Physician practices </option>
<option value="Exec">Exec </option>
<option value="Technical">Technical </option>
<option value="Administrative">Administrative </option>
<option value="Payers">Payers </option>
<option value="Labs">Labs </option>
<option value="Other">Other </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement15" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45586">Area of interest for this partnership? </label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45586" name="areaInterest" style="width:100%;" data-value="">
<option value="">Select </option>
<option value="Clinical Orders/Results">Clinical Orders/Results </option>
<option value="Clinical Decision Support">Clinical Decision Support </option>
<option value="Consumer Payments">Consumer Payments </option>
<option value="Coverage Insight">Coverage Insight </option>
<option value="Data and Analytics ">Data and Analytics </option>
<option value="EDI (Claims, Remits, Eligibility, etc)">EDI (Claims, Remits, Eligibility, etc) </option>
<option value="Electronic Chart Collaboration">Electronic Chart Collaboration </option>
<option value="Electronic ePrescribing">Electronic ePrescribing </option>
<option value="Electronic Prior Authorizations">Electronic Prior Authorizations </option>
<option value="Fraud, Waste and Abuse">Fraud, Waste and Abuse </option>
<option value="Population Health">Population Health </option>
<option value="Print Capabilities">Print Capabilities </option>
<option value="Revenue Cycle Management">Revenue Cycle Management </option>
<option value="Quality Solutions">Quality Solutions </option>
<option value="Payment Integrity Solutions">Payment Integrity Solutions </option>
<option value="Engagement Solutions">Engagement Solutions </option>
<option value="Payment Solutions">Payment Solutions </option>
<option value="Risk Adjustment Solutions">Risk Adjustment Solutions </option>
<option value="Network Solutions">Network Solutions </option>
<option value="Consulting">Consulting </option>
<option value="Write in/Other">Write in/Other </option>
<option value="APIs">APIs </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row full-width">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement16" class="elq-field-style form-element-layout row full-width">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe45587">Do you have other business relationships with Change Healthcare? <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select" id="fe45587" name="existingRelationship" style="width:100%;" data-value="" required="">
<option value="">Select </option>
<option value="Yes">Yes </option>
<option value="No">No </option>
</select>
</div>
</div>
</div>
</div>
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Conditions you may enter into with Change Healthcare.
2. Age Restrictions
This Site is a general audience site. Change Healthcare does not intend that any
portion of the Website will be accessed or used by children under the age of 13,
and such use is prohibited. If you use this Site, you affirm that you are at
least 18 years of age, or possess legal parental or guardian consent, and are
fully able and competent to enter into, and comply with, the terms, conditions,
obligations, affirmations, representations, and warranties set forth in these
Terms, our Privacy Notice, and our Purchase Terms and Conditions. Please contact
us at chiefprivacyofficer@ChangeHealthcare.com, if you believe your child has
provided us with personal information in connection with the Site.
3. Intellectual Property
All right, title, and interest in and to the Site and its content, features, and
functionality, including, but not limited to, products, information, materials,
text, graphics, photographs, illustrations, videos, displays, images, audio,
music, button icons, data compilations, files, software, other works of
authorship, and the design, selection, arrangement, and compilation thereof
(collectively "Content"), and all intellectual property rights in the Site, are
retained by Change Healthcare, our affiliates, our partners or our licensors,
and are protected by copyright, trademark, patent, intellectual property, and
other laws of the United States and foreign countries. You may access and use
our Site solely for personal, non-commercial purposes. No right, title or
interest in or to the Site is transferred to you, and all rights not expressly
granted are reserved by Change Healthcare. Except as expressly provided in these
Terms, you are expressly prohibited from copying, selling, assigning, licensing,
renting, reproducing, distributing, modifying, disassembling, decompiling,
reverse engineering, creating derivative works of, publicly displaying, publicly
performing, marketing, downloading, storing, transmitting, disclosing, or
otherwise exploiting any part of the Site or any Content available on or through
the Site without the express prior consent of Change Healthcare. You may use
information on our products and services purposely made available by Change
Healthcare for downloading from the Site, provided that you (1) do not remove or
alter any copyright, trademark, or other proprietary rights notice in any and
all copies of Content from the Site; (2) make no modifications to any Content or
copies of any Content from our Site; (3) do not use any pictures, photographs,
illustrations, video or audio sequences or any graphics separately from the
accompanying text; (4) not make any additional representations or warranties
relating to such information; (5) otherwise access or use any part of the Site,
or any Content available on or through the Site, for any purpose other than
personal use and consumption. Except as set forth in this Section 3, if you
access or use, or provide any other individual with access, to any part of the
Site in breach of these Terms, your right to use the Site will terminate
immediately and you must, at our option, return or destroy any copies of the
Content you made. Change Healthcare also reserves the right to terminate your
authorization to use any services available on or through the Site and any
related accounts immediately and at any time if you breach or threaten to breach
these Terms. The trademarks, logos, service marks, and product marks displayed
on the Site are the registered and unregistered marks of Change Healthcare, our
affiliates or related companies, our partners, or our licensors, and are
protected by U.S. and international trademark laws. All other trademarks not
owned by us, our affiliates or related companies, our partners or our licensors
that appear on the Site are the property of their respective owners, who may or
may not be affiliated with, connected to, or sponsored by us.
Digital Millennium Copyright Act ("DMCA") Takedown Notifications
Change Healthcare respects the intellectual property rights of others. If you
believe that your work has been copied, posted, stored, or otherwise transmitted
using the Site in a way that constitutes copyright infringement, please provide
the following information pursuant to the DMCA to the designated agent listed
below:
* an electronic or physical signature of a person authorized to act on behalf
of the owner of the copyright interest that is allegedly infringed;
* a clear and complete description of the copyrighted work that you claim has
been infringed; a clear and complete description of the material on the Site
that you claim to be infringing and a sufficient description of where the
material can be located to enable Change Healthcare to find and remove it;
* sufficient information to contact you, such as your address, telephone
number, and email address;
* a statement by you that you have a good faith belief that use of the material
in the manner complained of is not authorized by the copyright owner, its
agent, or the law; and
* a statement by you, made under penalty of perjury, that the information in
your notification is accurate and that you are the owner, or an agent
authorized to act on behalf of the owner, of an exclusive right that is
allegedly infringed.
The designated agent for claims of copyright infringement may be reached at:
e-mail Address: CopyrightRequests@changehealthcare.com
Postal Address:
Change Healthcare
Attn: Intellectual Property Counsel
5995 Windward Parkway
Alpharetta, GA 30005
Please reference: “DMCA Copyright Takedown” in your correspondence.
4. Accuracy of Information
We try to provide complete, accurate, up-to-date Content on our Site.
Unfortunately, it is not possible to ensure that any website is completely free
of human or technological errors. Notwithstanding our best efforts, our Site may
contain typographical inaccuracies, mistakes, or omissions, some of which may
relate to pricing and availability, and some Content may not be complete or
current. As a result, we do not warrant, nor are we responsible for, the
accuracy, reliability, completeness, or usefulness of the Content available on
or through our Site. We also have made every effort to display as accurately as
possible the colors, sizes, and shapes of any products that appear on our Site.
However, we cannot guarantee that your computer monitor’s display of any product
will be accurate. Pictures, photographs, images, videos, and graphics on our
Site are for illustration-purposes only. Not all products and services are
available in all geographic areas. Your eligibility for particular products and
services is subject to final determination and acceptance by the entity
providing such products or services and the provision of such products or
services is not an obligation of or guaranteed by Change Healthcare unless
Change Healthcare is identified as the entity providing such products or
services. The Content presented on or through our Site is made available solely
for informational purposes. The Site has been designed to provide general
information about Change Healthcare, its products and solutions and related
information. The Site is not intended to provide investment or medical advice,
nor does it provide instruction on the appropriate use of products or solutions
produced, supplied or under development by Change Healthcare, its affiliates,
related companies, or its licensors, business partners, or other companies. Any
reliance you place on Content available on or through our Site is strictly at
your own risk and we are not liable or responsible for any reliance place on our
Site’s Content. All users of the Site agree that all access and use of the Site,
and any and all Content presented on the Site, is at the user’s own risk. We
reserve the right to correct any errors, inaccuracies or omissions, and to
discontinue, add to, modify, upgrade, or replace all aspects of the Site in our
sole discretion and without notice. In particular, we reserve the right in our
sole discretion to modify, supplement, discontinue, or remove any Content
appearing on or transmitted through the Site. We also reserve the right to
adjust prices, products and any special offers at any time at our sole
discretion.
5. Prohibited Uses of the Site
When using the Site, you agree not to: (i) Disrupt, damage, interfere with,
violate the security of, or attempt to gain unauthorized access to, the Site or
any computer network; (ii) Circumvent any technological measure implemented by
Change Healthcare or any of our providers or any other third party (including
another user of the Site) to protect the Site; (iii) Use our Site in any manner
that could disable, overburden, damage, or impair our Site or interfere with any
other party’s use of our Site, including their ability to engage in real time
activities through our Site; (iv) Upload, transmit, distribute, or run any
computer virus, worm, Trojan horse, logic bomb, or any computer code or other
material that could harm or alter a computer, portable device, computer network,
communication network, data, the Site, or any other system, device or property;
(v) Use any software robots, spiders, crawlers, or other automatic device,
process or means to access our Site for any purpose, including monitoring or
copying any Content on our Site; (vi) Transmit, or cause the sending of any
advertising or promotional material without our prior written consent, including
any “junk mail,” “chain letter,” “spam” or any other similar solicitation; (vii)
Attempt, in any manner, to obtain the password, account, credentials, or other
security information from any other user; or jeopardize the security of your
account or anyone else’s account (for example, by allowing another individual to
login to the Site as you); (viii) Impersonate or attempt to impersonate Change
Healthcare, a Change Healthcare employee, another Site user or any other person
or entity (including, without limitation, by using email addresses or screen
names associated with any of the foregoing); (ix) Use our Site in any way that
violates any applicable federal, state, local or international law or regulation
(including, without limitation, any laws regarding the export of data or
software to and from the United States or other countries); (x) Send, knowingly
receive, upload, download, use or re-use any Content that does not comply with
the standards and requirements set out in these Terms; (xi) Engage in any other
conduct that restricts or inhibits anyone’s use or enjoyment of our Site, or
which, as determined by us, may harm us or users of our Site or expose them to
liability; or (xii) Otherwise attempt to interfere with the proper working of
our Site.
6. User Submissions
While we welcome your inquiries or feedback, Change Healthcare does not accept
or consider unsolicited ideas, including without limitation ideas for new
marketing ideas, new products, solutions or technologies, or new product names.
Please do not send any such unsolicited ideas. Our Site may contain certain
interactive features or services that allow users like you to post, upload,
publish, display, transmit, or submit (this activity is referred to as “Post”)
comments, suggestions, feedback, ideas, materials comments, communications,
information, or other Content on or through the Site (collectively “User
Submissions”). Any and all User Submissions will be treated as non-proprietary
and non-confidential. By Posting any User Submission, you grant Change
Healthcare and our business associates, and each of their and our respective
licensees, successors and assigns a royalty-free, perpetual, irrevocable,
world-wide, sub-licensable exclusive license to access, copy, modify, adapt,
reproduce, redistribute, publish, create derivative works from, compile,
arrange, display, disclose, or otherwise make use of User Submissions in any
form, media, or technology, whether now known or hereafter developed, alone or
as part of other works, for any purpose and in any way without due compensation
to you. Change Healthcare may sublicense its rights through multiple tiers of
sublicenses. Change Healthcare does not waive any right to use similar ideas
previously known to us or developed by us. If you Post a User Submission, you
represent and warrant that you own or otherwise control the rights to such a
User Submission and have the right to grant the license above to us and any of
our business associates, any licensees, and any successors and assigns. You
agree that you will not Post any User Submission of any type that infringes or
violates any rights of any party or otherwise does not comply with these Terms.
You may not use false identifying information or contact information,
impersonate any person or entity, or otherwise mislead us as to the origin of
any User Submission. You understand and acknowledge that you are solely
responsible for any User Submission you Post, and you have full responsibility
for such Submission, including its legality, reliability, accuracy and
appropriateness. We are not liable for the content or accuracy of any User
Submission Posted by you or any other user of our Site.
7. Your Account
If you use the Site, you may have the opportunity to register for an account
with us. As part of the registration or account creation process, you will
create login credentials by selecting a password and providing an e-mail
address. Each registration is for a single user only. You are not allowed to
share your registration login credentials or give your login credentials to
anyone else. You are responsible for maintaining the confidentiality of your
password and you agree to accept responsibility for all activities that occur
under your account or password. Change Healthcare is not liable for any loss or
damages arising from your failure to maintain the confidentiality of your
account. You are further responsible for ensuring that all information you
provide on our Site is correct, current, and complete. You agree that you will
not provide any false or misleading information during the registration process.
You have no right to transfer your account to any other individuals in any
manner. If you are accessing and using the Site on someone else's behalf, you
represent that you have the authority to bind that person as a principal to
these Terms, and you agree to accept liability for harm caused by any wrongful
use of the Site resulting from such access or use. You must notify us
immediately of any unauthorized access to or use of your user name or password
or any other breach of security that you become aware of. All information you
provide when you register for an account on our Site is governed by our Privacy
Notice, which is incorporated herein, and we may take any action with respect to
your information that is consistent with our Privacy Notice. We reserve the
right to refuse service or terminate accounts for any reason, in our sole
discretion without prior notice.
8. Links to Third Party Websites
This Site may contain links to third party websites ("Third Party Sites"). Links
to other Third Party Sites are provided solely as a convenience to you. We have
no control over such Third Party Sites, nor do we review, approve, monitor,
endorse, or make any representations or warranties with respect to such Third
Party Sites; therefore, we are not responsible or liable to you or to any party
for any materials, information advertising, products, services, or other content
on or available from such Third Party Sites. If you decide to access any Third
Party Sites, you do this entirely at your own risk. You acknowledge and agree
that Change Healthcare is not liable, either directly or indirectly, for any
damage or loss caused by or in connection with use of or reliance on any such
Third Party Sites.
9. Linking to the Site and Social Media Features
Linking to the Site: You may link to our Site’s landing page,
www.ChangeHealthcare.com, only if you comply with the requirements for Linking
to Change Healthcare’s Site. LINKING TO CHANGE HEALTHCARE'S SITE INDICATES THAT
YOU ACCEPT THESE TERMS AND THAT YOU WILL ABIDE BY THE REQUIREMENTS BELOW. IF YOU
DO NOT ACCEPT THESE TERMS AND AGREE TO ABIDE BY THESE REQUIREMENTS, DO NOT LINK
TO THIS SITE.
Requirements for Linking to Change Healthcare’s Site:
You may link to our Site’s homepage provided that you:
(i) Do so in a way that is fair, legal, and does not damage our reputation or
take advantage of it, or show Change Healthcare in a negative light.
(ii) Do not establish a link in any way that suggests any form of association,
approval or endorsement on our part without our express written consent.
(iii) Do not use the Change Healthcare logo or any of Change Healthcare
registered and unregistered trademarks and service marks without the express
prior written consent of Change Healthcare.
(iv) Do not present false, misleading or inaccurate information regarding Change
Healthcare or Change Healthcare's products or services.
(v) Do not establish a link from any website not owned by you.
(vi) Cause our Site or any portion of it to be displayed, or appear to be
displayed on any other site, for example by framing or in-line linking, or
otherwise create a browser or border environment around our Site or our Content.
(vii) Link to any part of the Site other than the landing page, for example by
deep linking.
(viii) Do not establish a link from any website containing content that could be
construed as illegal, distasteful, offensive, controversial, or otherwise not
suitable for all age groups.
(ix) Otherwise take any action with respect to the Site or the Content available
on or though this Site that is inconsistent with these Terms or that violates
applicable laws.
Social Media Features: Our Site may provide certain social media features that
enable you to:(i) link from your own or certain third-party websites to certain
Content on our Site; (ii) send emails or other communications with certain
Content, or links to certain Content, on this Site; (iii) cause portions of
content on this Site to be displayed or appear to be displayed on your own or
certain third-party websites. You may use the social media features available on
our Site only as they are provided by us, including with respect to any Content
displayed with such social media features. Your use of our social media features
must also be in accordance with any additional terms and conditions we provide
with respect to such features. You are solely responsible for complying with the
terms and conditions of any third party social media websites, applications, or
services with which you interact and you acknowledge that any information
Content that you Post on such third party social media websites, applications,
or services is subject to that third party’s privacy policies and other terms
and conditions, over which Change Healthcare has no control, and for which
Change Healthcare will in no event be liable. You agree to cooperate with Change
Healthcare in causing any unauthorized framing or linking to cease immediately.
We reserve the right to withdraw linking permission without notice and we may,
in our sole discretion, request that you remove any link to the Site. Upon
receipt of such request, you shall immediately remove such link. We may disable
all or any social media features and any links at any time without notice in our
discretion.
10. Indemnification
You agree to indemnify, defend and hold Change Healthcare and all of its
parents, affiliates or subsidiaries, agents, officers, directors, employees,
information providers, licensors and licensees (collectively "Indemnified
Parties") harmless from and against any and all liability and costs (including,
without limitation attorneys' fees and costs), incurred by the Indemnified
Parties in connection with your use of the Services or any claim in connection
with or resulting from any breach by you of these Terms. You agree to cooperate
fully in Change Healthcare's defense of any such claim. You agree that Change
Healthcare shall be entitled to select its own counsel, at your expense, to
defend it in connection with any claim subject to indemnification by you. You
agree that Change Healthcare, and not you, will have control over the defense of
any such claim. You further agree that you will not in any event settle any
matter involving Change Healthcare, whether or not the settlement binds or is on
behalf of Change Healthcare, without the written consent of Change Healthcare.
11. Representations and Warranties; Limitation of Liability
YOUR USE OF THE SITE IS AT YOUR SOLE RISK. TO THE MAXIMUM EXTENT PERMITTED BY
APPLICABLE LAW, THE SITE AND THE CONTENT AVAILABLE ON IT OR THROUGH IT ARE
PROVIDED FOR YOUR CONVENIENCE, “AS IS”, AND “AS AVAILABLE” WITH ALL FAULTS AND
ERRORS. CHANGE HEALTHCARE AND OUR AGENTS, SUPPLIERS AND LICENSORS EXPRESSLY
DISCLAIM ANY WARRANTIES AND CONDITIONS OF ANY KIND, WHETHER EXPRESS, IMPLIED, OR
STATUTORY, INCLUDING, WITHOUT LIMITATION, MERCHANTABILITY, FITNESS FOR A
PARTICULAR PURPOSE, ACCURACY, TITLE, QUIET ENJOYMENT, NON-INFRINGEMENT OF
THIRD-PARTY RIGHTS, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE
OF TRADE. WE DISCLAIM ALL WARRANTIES, GUARANTEES AND REPRESENTATIONS WITH
RESPECT TO THE COMPLETENESS, SECURITY, RELIABILITY, QUALITY, ACCURACY, COPYRIGHT
COMPLIANCE, LEGALITY, OR DECENCY IN RESPECT OF OUR SITE, INCLUDING BUT NOT
LIMITED TO ANY CONTENT CONTAINED ON OR ACCESSED THROUGH THE SITE. CHANGE
HEALTHCARE DOES NOT GUARANTEE THAT THE SITE WILL BE UNINTERRUPTED, OR FREE FROM
ERROR, DEFECT, LOSS, DELAY IN OPERATION, CORRUPTION, CYBER ATTACK, VIRUSES,
INTERFERENCE, HACKING, MALWARE, OR OTHER SECURITY INTRUSION, AND CHANGE
HEALTHCARE DISCLAIMS ANY LIABILITY RELATING THERETO. CHANGE HEALTHCARE MAKES NO
REPRESENTATIONS OR WARRANTIES REGARDING SUGGESTIONS OR RECOMMENDATIONS OF
PRODUCTS OR SERVICES OFFERED, DISPLAYED, OR PURCHASED THROUGH THE SITE. NO
ADVICE OR INFORMATION, WHETHER ORAL OR WRITTEN, OBTAINED BY YOU THROUGH THIS
SITE SHALL CREATE ANY WARRANTY NOT EXPRESSLY STATED IN THESE TERMS. CHANGE
HEALTHCARE DOES NOT WARRANT, ENDORSE, GUARANTEE, OR ASSUME RESPONSIBILITY FOR
ANY PRODUCT OR SERVICE ADVERTISED OR PROVIDED BY A THIRD PARTY THROUGH OR IN
CONNECTION WITH THE SITE OR ANY HYPERLINKED WEBSITE OR SERVICE. TO THE MAXIMUM
EXTENT PERMITTED BY APPLICABLE LAW, IN NO EVENT WILL CHANGE HEALTHCARE, our
affiliates, directors, officers, employees, agents, contractors, licensors,
suppliers, successors and assigns of each, be liable for any direct, indirect,
consequential, EXEMPLARY, special, incidental, punitive or other damages you or
others may suffer, including without limitation any damages for personal injury,
pain and suffering, emotional distress, LOST REVENUE, lost profits, LOSS OF
BUSINESS OR ANTICIPATED SAVINGS, LOSS OF GOODWILL, business interruption,
SERVICE INTERRUPTION, LOST DATA OR CONTENT, COMPUTER DAMAGE, COST OF SUBSTITUTE
SERVICES, INABILITY TO USE THE SITE, PRIVACY LEAKAGE, OR ANY OTHER LIABILITIES
OR LOSSES CAUSED BY THE SITE, ANY WEBSITES LINKED TO IT, ANY CONTENT ON OUR SITE
OR SUCH OTHER WEBSITES, ANY products or SERVICES accessed, viewed, or OBTAINED
THROUGH OUR SITE OR SUCH OTHER WEBSITES, ANY BREACH OF THESE TERMS, ANY ACT OR
OMISSION BY US OR OUR PERSONNEL, WHETHER OR NOT THE POSSIBILITY OF SUCH DAMAGES
HAS BEEN DISCLOSED IN ADVANCE OR COULD HAVE BEEN REASONABLY FORESEEN, REGARDLESS
OF THE LEGAL OR EQUITABLE THEORY (WARRANTY, CONTRACT, TORT OR OTHERWISE) UPON
WHICH THE CLAIM IS BASED, AND NOTWITHSTANDING THE FAILURE OF ANY AGREED OR OTHER
REMEDY OF ITS ESSENTIAL PURPOSE. TO THE EXTENT OUR LIABILITY HAS NOT BEEN
EXCLUDED OR LIMITED UNDER THESE TERMS, OUR AGGREGATE LIABILITY ARISING OUT OF OR
IN CONNECTION WITH THESE TERMS, WHETHER ARISING OUT OF OR RELATED TO BREACH OF
CONTRACT, TORT (INCLUDING NEGLIGENCE) OR OTHERWISE, WILL NOT EXCEED THE TOTAL OF
ANY AMOUNTS actually paid BY YOU FOR THE RELEVANT order. The EXCLUSIONS AND
LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BASIS OF
THE BARGAIN BETWEEN CHANGE HEALTHCARE AND YOU.
12. Disputes; Governing Law
You agree that any cause of action or claim that you may have relating to this
Site must be made or instituted within one year of when the cause of action or
claim accrued. You expressly agree that the Terms and any dispute, claim,
action, cause of action, issue, or request for relief between you and Change
Healthcare arising out of or relating to these Terms, your visit to our Site, or
to products or services obtained on or through the Web Site (collectively
“Disputes”) will be governed by and construed in accordance with the laws of the
State of Tennessee, U.S.A., without giving effect to any conflict of laws
principles that may provide the application of the law of another jurisdiction.
You and we irrevocably consent to the exclusive jurisdiction and venue of the
state or federal courts in Nashville, Tennessee for all Disputes that are heard
in court, including any Dispute involving Change Healthcare or its affiliates,
subsidiaries, employees, contractors, officers, directors, telecommunication
providers, and content providers.
13. Term and Termination
These Terms will remain in full force and effect as long as you continue to
access or use the Site. We may, with or without prior notice, terminate any of
the rights granted by these Terms without cause. You shall comply immediately
with any termination or other notice, including, as applicable, by ceasing all
use of the Site.
14. Entire Agreement; No Agency; Waiver; Severability
Entire Agreement: These Terms, together with our Privacy Notice and applicable
Purchase Terms & Conditions, constitute the complete and exclusive understanding
between you and Change Healthcare with respect to your use of the Site, and
these Terms supersede and replace any and all prior oral or written
understandings or agreements between Change Healthcare and you regarding the
Site.
No Agency: Nothing contained in these Terms creates any agency, partnership, or
other form of joint enterprise between you and Change Healthcare.
Waiver: Change Healthcare’s failure to enforce any right or provision in these
Terms will not constitute a waiver of such right or provision or of any other
rights or provisions in these Terms.
Severability: If a court or tribunal should find that one or more rights or
provisions set forth in these Terms are invalid, you agree that the remainder of
the Terms will remain in full force and effect and that the invalid provision
will be enforceable to the fullest extent permitted by law. We will amend or
replace such provisions with ones that are valid and enforceable and which
achieve, to the extent possible, our original objectives and intent as reflected
in the original provisions.
Contact Us:
If you have any questions regarding these Terms, please contact us by email
at chiefprivacyofficer@ChangeHealthcare.com.
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