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31 <br />Attachment 3 <br />Onboarding & Technical Specifications <br />Participant Background Information <br />1. Type of facility or system:Please select all that apply below. <br />……Hospital, Health <br />System, or <br />Regional HIE <br />……Ambulatory/ <br />Outpatient <br />Clinic <br />……Laboratory ……Pharmacy ……Other Please specify: <br />_____________________ <br />2. Provider type: <br />This field is not required if your organization is a Hospital, Health System, Regional HIE, Laboratory, or Pharmacy <br />……Primary Care ……Dental or Orthodontic ……Respiratory, Developmental, <br />Rehabilitative or Restorative <br />……Pediatrics ……Residential Facility ……Speech, Language and <br />Hearing <br />……OB/GYN ……In Home Care, e.g. PCS, CAP- <br />C/DA, etc. <br /> <br />……Other Please specify: <br />_________________________……Behavioral Health ……Eye & Vision <br />3. Participant Organization National Provider <br />Identifier (NPI):________________________________ <br />4. How many Participating Entities (PEs) or <br />facility locations does your organization have? <br />If you have any PEs or more than one facility <br />location, please complete Attachment 4 _______ <br />5. Is your provider or health system a part of one or more the following?……Yes ……No <br />If yes, please select all that apply and list the name of the organization(s). <br />…Health system <br />…Regional HIE <br />…Accountable Care Organization <br />…Clinically Integrated Network <br />Substance Use Disorder Treatment Information <br />6. Does your organization or any unit within <br />your organization provide Substance Use <br />Disorder treatment? <br />…Yes …No <br />7. If yes to 6, does your organization fall under <br />42 C.F.R. Part 2? <br />If unsure, please contact your legal counsel and visit the <br />SAMHSA website at www.SAMHSA.gov <br />…Yes …No <br /> <br />Electronic Health Record (EHR Vendor) Information <br />Please discuss these questions with your Technical Services Contact <br />8. EHR Vendor: <br />Emergency Medical Services <br />EMS Care <br />1629178629 <br />1 <br />ESO Solutions <br />✔ <br />✔ <br />✔ <br />✔ <br />DocuSign Envelope ID: 47B4445A-C7CA-4D2E-9075-2AFD82F82DEC