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Organization Demographics |
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Purpose |
The Organization Demographics accordion tab captures the organizations demographic information like the Organization Name, Physical Address, etc. During an organization's renewal, this tab will be prepopulated with the information filled in earlier.
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Required Fields |
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Field Name |
Description |
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Organization Name |
Required. Enter organization's name. |
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Organization Physical Address |
Required. Enter organization's physical address. |
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Physical Address Line 2 |
Enter organization's other physical address like Suite # or Apt # |
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City |
Required. Enter the city the organization is in. |
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County |
Required. Enter the county the organization belongs to. |
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State |
Required. Enter the State the organization is set up in. |
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Zip Code |
Required. Enter the organization's zip code. |
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Zip +4 |
Enter the organization's zip +4 code, if known. |
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Phone Number |
Required. Enter the organization's phone number. |
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Fax Number |
Enter the organization's fax number. |
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Organization Email |
Enter the organization's email. |
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Organization Mailing Address |
Required. Enter the mailing address of the organization. Select the check box if your organization's Mailing address is same as the Physical Address |
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Mailing Address Line 2 |
Enter the organization's other mailing address like Suite # or Apt # |
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City |
Required. Enter the city for the organization's mailing address. |
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State |
Required. Enter the State for the organization's mailing address. |
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Zip Code |
Required. Enter the organization's mailing address zip code. |
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Zip +4 |
Enter the organization's mailing address zip +4 code, if known. |
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Organization Medicaid ID |
Displayed only the organization administers immunizations. Enter the organization's Medicaid ID. |
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Button Name |
Description |
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Will save the information entered and notification email will be sent to the organization's point of contact and the authorized signer, with a unique random access code. Once this code is accessed to return to the form, any other previously generated code will expire. |