DHMW 3rd Party Authorization Form

Your First Name*

Your Last Name*

Organization*

Job title*

Your Email Address*

Name of Approved 3rd Party Contact*

Email For Approved 3rd Party Contact

Approved 3rd Party Organization*

Terms and Conditions For Authorization

Digital Health Analytics is a market intelligence and survey research hub putting unprecedented resources at your fingertips. As a previous participant in the Digital Health Most Wired Survey, you have automatic and free access to this new personalized, confidential, portal. We recognize how valuable DHMW reports are to participating healthcare organization (HCOs). We are also sensitive to the time required to complete the survey. By completing the form above, you are authorizing a 3^rd party contact, from an outside organization to de-identified reports and data associated with your organization through the Digital Health Most Wired Survey. Further, completion of this form and the attestations below confirm that you understand that the 3^rd part participant, listed above, will have access to populate the collection tool for the Digital Health Most Survey, but final review and submission is your executive responsibility.

DHMW 3rd Party Attestation Statements*

I hereby authorize the 3rd party participant, listed above, to have access to our complimentary Provider portal through Digital Health Analytics

I hereby authorize the 3rd party participant, listed above, to have access to our data collection tool and submit responses on behalf of my organization for the Digital Health Most Wired Survey

I understand and acknowledge that the 3rd party participant, listed above, will have their access to DHA removed effective June 13, 2022 at the close of the DHMW award grading period

I affirm that I am either the senior executive leader for my organization that is responsible for the Digital Health Most Wired Survey submission, or I have received approval for our executive to execute this authorization