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<!DOCTYPE html>  <html class="no-js" lang="en" > <head> <meta http-equiv="X-UA-Compatible" content="IE=edge" /> <meta charset="utf-8" /> <meta name="viewport" content="width=device-width, initial-scale=1.0" /> <title>Register - Genoa Online</title> <link href="/favicon.ico" rel="shortcut icon" type="image/x-icon" />  <script async src="https://www.googletagmanager.com/gtag/js?id=UA-84650962-3"></script> <script src="/js/Shared/_LayoutHead.js"></script> <link rel="stylesheet" href="/Content/css.css" /> </head> <body> <div class="red-bar"></div> <header> <div class="row"> <div class="large-5 columns"> <a href="http://www.genoahealthcare.com/"><img class="logo" src="https://assets.genoahealthcare.com/images/genoa_healthcare_logo.png" alt="Genoa Healthcare" /></a> </div> <div class="large-7 columns show-for-large-up"> </div> </div> </header> <div class="nav-bar"> <div class="row"> <div class="large-12 columns"> <nav class="top-bar" data-topbar role="navigation"> <ul class="title-area hide-for-medium-up"> <li class="name"> <h1></h1> </li> <li class="toggle-topbar menu-icon"><a href="#"><span></span></a></li> </ul> <section class="top-bar-section"> <ul> <li ><a href="/Account/Login" id="loginLink" title="Log In">Log In</a></li> <li class="active"><a href="/Account/Register" id="registerLink" title="Register">Register</a></li> </ul> </section> </nav> </div> </div> </div> <div class="sub-nav-bar"> </div> <div class="docs-wrap"> <div class="inner-wrap"> <section class="main-section"> <div class="row"> <div class="large-12 columns"> <br> <section class="content-wrapper main-content clear-fix"> <form action="/Account/Register" id="register-form" method="post" name="register-form"> <div class="row"> <div class="large-12 columns"> <h3>Genoa Online Request Access Form</h3> </div> </div> <div class="alert-box info radius"> Genoa Online access is for partner staff members only. It is not for consumers at this time. </div> <div class="panel callout"> <ul> <li>This form must be filled out by providers or employees of community mental health organizations (centers) affiliated with Genoa in order to gain access to the Genoa Online tools for the purposes of treatment, payment and operations for consumers under their direct care.</li> <li>A corporate email address must be used to gain access to Genoa Online. If a corporate email address is not available, the exception needs to be explained and approved by the Director of Operations and sent to <a href="mailto:genoaonline@genoa-qol.com">genoaonline@genoa-qol.com</a>.</li> <li>Passwords must change every 90 days or a user will be locked out of the system until he or she changes the password.</li> <li>The information contained in the Genoa Online tools is protected by the same HIPAA regulations as all other PHI. Please follow the same precautions you would handling this information in any other situation.</li> <li>It is a users’ responsibility to inform Genoa, if they are no longer going to need access to Genoa Online by emailing <a href="mailto:genoaonline@genoa-qol.com">genoaonline@genoa-qol.com</a>.</li> </ul> </div> <div class="panel validation-summary-valid" data-valmsg-summary="true"><span>Registration errors</span> <ul><li style="display:none"></li> </ul></div> <div class="row"> <div class="large-12 columns"> <label for="Pharmacy_Key">Please select the location of your Genoa pharmacy</label> <select data-val="true" data-val-range="Please select a Genoa pharmacy" data-val-range-max="2147483647" data-val-range-min="0" data-val-required="The Please select the location of your Genoa pharmacy field is required." id="Pharmacy_Key" name="Pharmacy_Key" style="background-position-x : 99%"><option value="-1">Select a Genoa pharmacy</option> <option value="3">00003-Auburn, WA, Corp Genoa - Auburn WA</option> <option value="5">00005-Everett, WA, Compass Health</option> <option value="7">00007-Providence, RI, Providence Center</option> <option value="8">00008-Bremerton, WA, Kitsap Mental Health Services</option> <option value="10">00010-Chattanooga, TN, Volunteer Behavioral Health- Johnson Mental Health Center</option> <option value="11">00011-Belleville, IL, Chestnut Health Systems, Inc.</option> <option value="12">00012-Thornton, CO, Community Reach Center</option> <option value="14">00014-Bradenton, FL, Centerstone of Florida, Inc.</option> <option value="16">00016-Bloomington, IN, Centerstone of Indiana - Bloomington</option> <option value="18">00018-Benton Harbor, MI, Riverwood Center</option> <option value="19">00019-Lakewood, WA, Greater Lakes Mental Healthcare</option> <option value="21">00021-Fort Myers, FL, SalusCare</option> <option value="22">00022-Seattle, WA, Sound</option> <option value="23">00023-Kissimmee, FL, Park Place Behavioral Health Care</option> <option value="26">00026-Watertown, SD, Human Service Agency</option> <option value="28">00028-Gainesville, FL, Meridian Behavioral Healthcare</option> <option value="29">00029-Toledo, OH, Harbor</option> <option value="30">00030-Winter Haven, FL, Center for Behavioral Health Division of Winter Haven Hospital</option> <option value="31">00031-Jeffersonville, IN, LifeSpring</option> <option value="32">00032-Indiana, PA, Community Guidance Center</option> <option value="33">00033-Fort Wayne, IN, Park Center, Inc</option> <option value="35">00035-Carmel, IN, Aspire Indiana Behavioral Health System</option> <option value="36">00036-Red Bank, NJ, CPC Behavioral Health</option> <option value="37">00037-Cookeville, TN, Volunteer Behavioral Health- Plateau Mental Health Center</option> <option value="38">00038-Athens, TN, Volunteer Behavioral Health- Hiwassee Mental Health Center</option> <option value="40">00040-Kansas City, KS, Wyandot Center</option> <option value="41">00041-Madison, WI, Journey Mental Health Center, Inc.</option> <option value="43">00043-New London, CT, Sound Community Services, Inc.</option> <option value="45">00045-McMinnville, TN, Volunteer Behavioral Health- Cheer Mental Health</option> <option value="47">00047-Cheyenne, WY, Volunteers of America Northern Rockies - Cheyenne, WY</option> <option value="48">00048-Independence, MO, Comprehensive Mental Health Services, Inc.</option> <option value="49">00049-Yakima, WA, Central Washington Comprehensive Mental Health</option> <option value="50">00050-Anderson, IN, Aspire Indiana Behavioral Health System</option> <option value="52">00052-St. Paul, MN, Corp Genoa - St. Paul, MN</option> <option value="53">00053-Cleveland, TN, Volunteer Behavioral Health- Hiwassee Mental Health Center</option> <option value="55">00055-Marietta, GA, Cobb County Community Services Board</option> <option value="56">00056-Lexington, KY, New Vista</option> <option value="58">00058-Muncie, IN, Meridian Health Services</option> <option value="59">00059-Evansville, IN, Southwestern Behavior Healthcare, Inc.</option> <option value="60">00060-Salem, OR, Marion County Health Department</option> <option value="61">00061-St. Paul, MN, People, Inc.</option> <option value="62">00062-Indianapolis, IN, Adult & Child Mental Health Center Incorporated</option> <option value="66">00066-Murfreesboro, TN, Volunteer Behavioral Health- The Guidance Center</option> <option value="67">00067-Lees Summit, MO, ReDiscover- Lee's Summit</option> <option value="68">00068-Springdale, AR, Ozark Guidance Center, Inc.</option> <option value="69">00069-Columbus, OH, North Central Mental Health Services</option> <option value="70">00070-Elkhart, IN, Oaklawn Psychiatric Center, Inc.</option> <option value="71">00071-Tucson, AZ, La Frontera Center, Inc.</option> <option value="72">00072-Willoughby, OH, Central Pharmacy</option> <option value="73">00073-Lakewood, NJ, Preferred Behavioral Health of NJ, Inc.</option> <option value="74">00074-Dayville, CT, United Services, Inc.</option> <option value="75">00075-Meriden, CT, Rushford Center</option> <option value="76">00076-Manchester, CT, Community Health Resources, Inc. "CHR"</option> <option value="77">00077-Shawnee, KS, Johnson County Mental Health Center</option> <option value="78">00078-Wooster, OH, The Counseling Center</option> <option value="79">00079-St. Joseph, MO, Family Guidance Center</option> <option value="80">00080-New Brighton, MN, Nystrom & Associates, Ltd.</option> <option value="81">00081-Topeka, KS, Valeo Behavioral Health Care</option> <option value="82">00082-Hackensack, NJ, Comprehensive Behavioral Healthcare, Inc.</option> <option value="83">00083-Coon Rapids, MN, Family Life Center</option> <option value="86">00086-Portland, OR, LifeWorks Northwest</option> <option value="87">00087-Lafayette, IN, Wabash Valley Alliance d/b/a Valley Oaks Health</option> <option value="88">00088-Decatur, IL, Heritage Behavioral Health Care, Inc.</option> <option value="89">00089-Duluth, MN, Human Development Center</option> <option value="90">00090-Barrington, RI, East Bay Center</option> <option value="91">00091-Leesburg, FL, LifeStream Behavioral Healthcare</option> <option value="92">00092-Knoxville, TN, Helen Ross McNabb Center</option> <option value="93">00093-Roseville, MN, Clozapine/Central Pharmacy 00093</option> <option value="94">00094-Roanoke, VA, Blue Ridge Behavioral Healthcare</option> <option value="95">00095-South Bend, IN, Oaklawn Psychiatric Center, Inc.</option> <option value="96">00096-Salt Lake City, UT, Central Pharmacy</option> <option value="97">00097-St. Louis Park, MN, Associated Clinic of Psychology</option> <option value="98">00098-Cape Girardeau, MO, Community Counseling Center</option> <option value="99">00099-Kokomo, IN, Community Howard Regional Health, Inc.</option> <option value="100">00100-Ladue, MO, Clayton Behavioral</option> <option value="101">00101-Rockford, IL, Milestone, Inc.</option> <option value="102">00102-Carmel, IN, Indiana Health Group</option> <option value="103">00103-Granite City, IL, Chestnut Health Systems at Northgate</option> <option value="104">00104-Leavenworth, KS, The Guidance Center - Kansas</option> <option value="105">00105-Johnstown, PA, Nulton Diagnostic and Treatment Center</option> <option value="106">00106-Elgin, IL, Ecker Center for Behavioral Health, Inc.</option> <option value="107">00107-Bayville, NJ, Ocean Mental Health Services Inc</option> <option value="108">00108-Howell, MI, Livingston County Community Mental Health Authority</option> <option value="109">00109-Hot Springs, AR, Ouachita Behavioral Health and Wellness</option> <option value="110">00110-Kansas City, MO, Tri-County Mental Health Services</option> <option value="111">00111-Chattanooga, TN, Helen Ross McNabb Center</option> <option value="112">00112-Milwaukee, WI, American Behavioral Clinics</option> <option value="113">00113-Kansas City, MO, ReDiscover South</option> <option value="114">00114-Woodbury, MN, Nystrom & Associates, Ltd.</option> <option value="115">00115-Lancaster, PA, Community Services Group</option> <option value="116">00116-Lawrenceville, GA, View Point Health</option> <option value="117">00117-Little Rock, AR, Arkansas Psychiatric Clinic</option> <option value="118">00118-Logansport, IN, Four County Counseling Center</option> <option value="119">00119-Danville, VA, Danville-Pittsylvania CSB</option> <option value="120">00120-Topeka, KS, Family Service and Guidance Center of Topeka, Inc.</option> <option value="122">00122-Washington, DC, Community Connections</option> <option value="123">00123-Cape May Court House, NJ, Acenda Integrated Health</option> <option value="124">00124-Warwick, RI, Quality Behavioral Health</option> <option value="125">00125-Lynchburg, VA, Horizon Behavioral Health</option> <option value="126">00126-Peoria, IL, Human Service Center</option> <option value="127">00127-Enfield, CT, Community Health Resources</option> <option value="129">00129-Monroe, MI, Monroe Community Mental Health Authority</option> <option value="130">00130-Middletown, CT, Gilead Community Services</option> <option value="131">00131-Owatonna, MN, South Central Human Relations Center</option> <option value="132">00132-St. Paul, MN, Guild, Incorporated</option> <option value="133">00133-Ocala, FL, The Centers Inc</option> <option value="134">00134-Plainville, CT, Wheeler Clinic Inc</option> <option value="135">00135-Washington, PA, Washington Communities Human Services, Inc.</option> <option value="136">00136-Milford, CT, Bridges Healthcare</option> <option value="137">00137-Greenfield, MA, ServiceNet, Inc.</option> <option value="138">00138-Goshen, IN, Oaklawn Psychiatric Center</option> <option value="139">00139-El Paso, TX, Emergence Health Network - Central Office (Main Account)</option> <option value="140">00140-Woonsocket, RI, Central Pharmacy - Woonsocket, RI</option> <option value="141">00141-Prince Frederick, MD, Calvert County Mental Health Clinic</option> <option value="142">00142-La Crosse, WI, Family & Children's Center</option> <option value="143">00143-Manchester, NH, The Mental Health Center of Greater Manchester</option> <option value="144">00144-Johnstown, PA, Alternative Community Resource Program, Inc.</option> <option value="145">00145-St. Cloud, MN, Central Minnesota Mental Health Center</option> <option value="146">00146-Anchorage, AK, Alaska Behavioral Health</option> <option value="147">00147-El Paso, TX, Emergence Health Network - East Valley Office</option> <option value="150">00150-Norwich, CT, United Community & Family Services</option> <option value="151">00151-Asheville, NC, Family Preservation Services of North Carolina, Inc.</option> <option value="152">00152-Chicago, IL, Trilogy, Inc.</option> <option value="153">00153-Ann Arbor, MI, Washtenaw County Community Mental Health Agency</option> <option value="154">00154-Lees Summit, MO, ReDiscover East</option> <option value="155">00155-Wheaton, IL, DuPage County Health Department: Mental Health</option> <option value="156">00156-Waukesha, WI, Waukesha County Department of Health and Human Services</option> <option value="157">00157-Emporia, KS, Crosswinds, Counseling and Wellness</option> <option value="10001">10001-Pittsburgh, PA, Central Pharmacy</option> <option value="10002">10002-Pottstown, PA, Creative Health Services, Inc.</option> <option value="10020">10020-St. Petersburg, FL, Suncoast Center, Inc.</option> <option value="10030">10030-Youngstown, OH, Coleman Health Services</option> <option value="10032">10032-Moraine, OH, South Community Behavioral Healthcare</option> <option value="10034">10034-Cincinnati, OH, Greater Cincinnati Behavioral Health Services</option> <option value="10036">10036-Akron, OH, Portage Path Behavioral Health</option> <option value="10038">10038-Kent, OH, Coleman Health Services</option> <option value="10050">10050-Tyler, TX, Andrews Center</option> <option value="10055">10055-Edinburg, TX, Tropical Texas Behavioral Health</option> <option value="10065">10065-Louisville, KY, Seven Counties Services</option> <option value="10080">10080-Merrillville, IN, Regional Mental Health Center</option> <option value="10082">10082-Valparaiso, IN, Porter-Starke Services, Inc.</option> <option value="10084">10084-Terre Haute, IN, Hamilton Center, Inc.</option> <option value="10090">10090-Yuma, AZ, Community Partners Integrated Healthcare Inc.</option> <option value="10100">10100-Philadelphia, PA, COMHAR</option> <option value="10110">10110-Pueblo, CO, Health Solutions</option> <option value="10112">10112-Colorado Springs, CO, Diversus Health</option> <option value="10130">10130-Wentzville, MO, Compass Health, Inc. d/b/a Compass Health Network</option> <option value="10140">10140-Derry, NH, The Center for Life Management</option> <option value="10150">10150-Auburn, WA, Valley Cities Counseling and Consultation</option> <option value="10160">10160-Princeton, WV, Southern Highlands CMHC</option> <option value="10170">10170-McHenry, IL, Association for Individual Development (AIDs)</option> <option value="10230">10230-Cincinnati, OH, Talbert House - Cincinnati, OH (Victory Parkway)</option> <option value="10240">10240-Newark, OH, Behavioral Healthcare Partners of Central Ohio</option> <option value="10260">10260-Louisville, KY, Seven Counties Services</option> <option value="10270">10270-Hays, KS, High Plains Mental Health Center</option> <option value="10290">10290-Loveland, CO, SummitStone Health Partners</option> <option value="10300">10300-McKeesport, PA, Coleman Health Services</option> <option value="10310">10310-East Chicago, IN, Regional Mental Health Center</option> <option value="10320">10320-Lawrenceburg, IN, Community Mental Health Center, Inc.</option> <option value="10330">10330-Panama City, FL, Life Management Center</option> <option value="10350">10350-Vincennes, IN, Samaritan Center</option> <option value="10360">10360-Marion, IN, Cornerstone Behavioral Health</option> <option value="10380">10380-Avon, IN, Cummins Behavioral Health System</option> <option value="10390">10390-Independence, KS, Four County Mental Health Center</option> <option value="10400">10400-Phoenix, AZ, Terros Health</option> <option value="10410">10410-Chicago, IL, Community Counseling Centers of Chicago </option> <option value="10430">10430-Parkersburg, WV, Westbrook Health Services</option> <option value="10440">10440-Alexandria, VA, Fairfax County CSB - Gartland Center</option> <option value="10450">10450-Fairfax, VA, Fairfax County CSB - Merrifield Center</option> <option value="10470">10470-Apache Junction, AZ, Horizon Health and Wellness</option> <option value="10480">10480-Rochester, MN, Zumbro Valley Health Center</option> <option value="10490">10490-Douglas, AZ, Community Health Associates - Douglas, AZ</option> <option value="10500">10500-Albany, GA, Aspire Behavioral Health</option> <option value="10510">10510-Payson, AZ, Southwest Behavioral & Health Services</option> <option value="10520">10520-Gary, IN, Edgewater Systems for Balanced Living, Inc.</option> <option value="10540">10540-Sierra Vista, AZ, Southeastern Arizona Behavioral Health Services, Inc.</option> <option value="10550">10550-Detroit, MI, Development Centers, Inc.</option> <option value="10560">10560-Detroit, MI, Covenant Community Care</option> <option value="10570">10570-Detroit, MI, Southwest Counseling Solutions</option> <option value="10580">10580-Clearwater, FL, Directions for Living</option> <option value="10600">10600-Greeley, CO, North Range Behavioral Health</option> <option value="10620">10620-Baton Rouge, LA, Capital Area Human Services - Baton Rouge, LA</option> <option value="10630">10630-Lima, OH, Coleman Health Services</option> <option value="10640">10640-Youngstown, OH, One Health Ohio</option> <option value="10650">10650-Warren, OH, One Health Ohio</option> <option value="10660">10660-Potosi, MO, Great Mines Health Center</option> <option value="10670">10670-Warrenton, MO, Compass Health, Inc. d/b/a Compass Health Network</option> <option value="10680">10680-Union, MO, Compass Health, Inc. d/b/a Compass Health Network</option> <option value="10690">10690-Tucson, AZ, COPE Community Services, Inc.</option> <option value="10700">10700-Mesa, AZ, Southwest Behavioral & Health Services</option> <option value="10710">10710-Tempe, AZ, Terros Health</option> <option value="10720">10720-Hutchinson, KS, Horizons Mental Health Center</option> <option value="10740">10740-Phoenix, AZ, Partners In Recovery</option> <option value="10780">10780-Kerrville, TX, Hill Country MHDDC</option> <option value="10790">10790-Columbia, SC, Central Pharmacy</option> <option value="10800">10800-Waxahachie, TX, Central Pharmacy - Waxahachie, TX</option> <option value="10812">10812-Rockford, IL, Rosecrance</option> <option value="10820">10820-Phoenix, AZ, Terros Health</option> <option value="10840">10840-Greensboro, NC, Monarch</option> <option value="10850">10850-Tucson, AZ, CODAC Health, Recovery & Wellness, Inc.</option> <option value="10860">10860-Thomasville, GA, Georgia Pines CSB</option> <option value="10870">10870-Grand Junction, CO, Mind Springs Health</option> <option value="10880">10880-Show Low, AZ, Change Point Integrated Health - Show Low, AZ</option> <option value="10882">10882-Cottonwood, AZ, Spectrum Healthcare</option> <option value="10884">10884-Flagstaff, AZ, The Guidance Center</option> <option value="10890">10890-Harlingen, TX, Tropical Texas Behavioral Health</option> <option value="10910">10910-Marrero, LA, Jefferson Parish Human Services Authority</option> <option value="10916">10916-New Orleans, LA, Metropolitan Human Services District</option> <option value="10918">10918-Redford, MI, Lincoln Behavioral Services</option> <option value="10920">10920-Tucson, AZ, CODAC Health, Recovery & Wellness, Inc.</option> <option value="10922">10922-Canton, OH, Coleman Health Services</option> <option value="10926">10926-Cincinnati, OH, Talbert House</option> <option value="10928">10928-Burlington, NC, RHA Health Services</option> <option value="10930">10930-Asheville, NC, October Road</option> <option value="10938">10938-Lake Charles, LA, Imperial Calcasieu Human Services Authority</option> <option value="10940">10940-Butler, PA, The Care Center Inc. building</option> <option value="10942">10942-Ashtabula, OH, Community Counseling Center - Ashtabula, OH</option> <option value="10944">10944-Toledo, OH, Zepf Center</option> <option value="10948">10948-Phoenix, AZ, Valle de Sol</option> <option value="10950">10950-Fort Walton, FL, Bridgeway Center, Inc.</option> <option value="10952">10952-Staunton, VA, Valley Community Service Board</option> <option value="10954">10954-Phoenix, AZ, Jewish Family & Children Services</option> <option value="10956">10956-Decatur, GA, Clifton Springs Mental Health Center</option> <option value="10958">10958-Decatur, GA, Winn Way Mental Health Center</option> <option value="10960">10960-Atlanta, GA, Kirkwood Mental Health Center</option> <option value="10964">10964-Blacksburg, VA, New River Valley CSB</option> <option value="10966">10966-Wichita, KS, The Mental Health Association of South Central Kansas</option> <option value="10968">10968-Charlotte, NC, Monarch - Charlotte</option> <option value="10970">10970-Roanoke Rapids, NC, RHA Health Services</option> <option value="10974">10974-Lincoln, NE, Lutheran Family Services of Nebraska, Inc. -Lincoln South</option> <option value="10976">10976-Prescott, AZ, Polara Health (Whipple Street)</option> <option value="10978">10978-Laconia, NH, Lakes Region Mental Health</option> <option value="20001">20001-Savannah, GA, Gateway Behavioral Health Services</option> <option value="20002">20002-Portsmouth, OH, Shawnee Family Health Center</option> <option value="20003">20003-Longview, WA, Columbia Wellness</option> <option value="20004">20004-Fort Wayne, IN, The Bowen Center</option> <option value="20006">20006-Salina, KS, Central Kansas Mental Health Center</option> <option value="20007">20007-Marlborough, MA, Advocates, Inc.</option> <option value="20008">20008-Bangor, ME, Community Health and Counseling Services</option> <option value="20009">20009-Beaumont, TX, Spindletop Center</option> <option value="20010">20010-Fort Smith, AR, Western Arkansas Counseling and Guidance Center</option> <option value="20011">20011-Nashua, NH, Greater Nashua Mental Health Center</option> <option value="20012">20012-Vancouver, WA, Community Services Northwest</option> <option value="20013">20013-Waukegan, IL, Lake County Health Department, Behavioral Health Services</option> <option value="20014">20014-Camden, NJ, South Jersey Behavioral Health Resources, Inc.</option> <option value="20015">20015-Canton, OH, CommQuest Services Inc.</option> <option value="20016">20016-East Hartford, CT, InterrCommunity, Inc.</option> <option value="20017">20017-Yuma, AZ, Community Health Associates - Yuma, AZ</option> <option value="20018">20018-Albuquerque, NM, Sage Neuroscience Center</option> <option value="20019">20019-Johnson City, TN, Frontier Health</option> <option value="20021">20021-Montgomery, AL, Montgomery Area Mental Health Authority</option> <option value="20022">20022-Bessemer, AL, Bessemer Neighborhood Health Center - Bessemer, AL</option> <option value="20023">20023-Attalla, AL, CED Mental Health Center</option> <option value="20024">20024-Rome, GA, Highland Rivers Center</option> <option value="20025">20025-Dothan, AL, Spectracare Mental Health System</option> <option value="20026">20026-Mobile, AL, Central Pharmacy 20026</option> <option value="20027">20027-Jackson, MS, Hinds Behavioral Health Services</option> <option value="20028">20028-Chardon, OH, Ravenwood Health</option> <option value="20029">20029-Fort Wayne, IN, Park Center Inc.</option> <option value="20030">20030-Jackson, WI, Central Pharmacy</option> <option value="20031">20031-Lincoln Park, MI, Community Care Services (MI)</option> <option value="20032">20032-Metairie, LA, Jefferson Parish HSA-East Bank</option> <option value="20033">20033-Westerville, OH, Concord Counseling Services</option> <option value="20034">20034-Amelia, OH, Greater Cincinnati Behavioral Health Services - Amelia</option> <option value="20035">20035-San Antonio, TX, Clarity Child Guidance Center</option> <option value="20036">20036-Englewood, NJ, Vantage Health System</option> <option value="20037">20037-Fort Lauderdale, FL, Henderson Behavioral Health - Central Branch</option> <option value="20038">20038-Tamarac, FL, Henderson Behavioral Health</option> <option value="20039">20039-Greenwood, IN, Valle Vista Health System</option> <option value="20040">20040-Casa Grande, AZ, Horizon Health & Wellness</option> <option value="20043">20043-Hammond, LA, Florida Parishes Human Services Authority</option> <option value="20044">20044-Brunswick, GA, Gateway Behavioral Health Services - Glynn</option> <option value="20045">20045-West Bend, WI, Washington County Mental Health Center</option> <option value="20047">20047-Alton, IL, Centerstone</option> <option value="20048">20048-Aurora, CO, Aurora Mental Health Center</option> <option value="20049">20049-Lake City, FL, Meridian Behavioral Healthcare - Lake City</option> <option value="20050">20050-Hampton, VA, Hampton-Newport News Community Services Board</option> <option value="20052">20052-Rochester, NH, Community Partners</option> <option value="20053">20053-Oregon City, OR, Beavercreek Health Center</option> <option value="20054">20054-Bay Shore, NY, Family Service League</option> <option value="20055">20055-St. Paul, MN, Radias Health</option> <option value="20056">20056-Brownsville, TX, Tropical Texas Behavioral Health</option> <option value="20057">20057-Wilkes-Barre, PA, Children's Service Center</option> <option value="20058">20058-Naples, FL, David Lawrence Center</option> <option value="20059">20059-Winston-Salem, NC, Monarch Winston-Salem</option> <option value="20060">20060-Dalton, GA, Highland Rivers - Dalton, GA</option> <option value="20061">20061-Culpeper, VA, Rappahannock-Rapidan CSB</option> <option value="20062">20062-Broken Arrow, OK, Strength of Mind</option> <option value="20063">20063-Montrose, CO, The Center for Mental Health</option> <option value="20064">20064-St. Charles, MO, Compass Health, Inc. d/b/a Compass Health Network</option> <option value="20065">20065-Casper, WY, Central Wyoming Counseling Center</option> <option value="20066">20066-Omaha, NE, Community Alliance</option> <option value="20067">20067-Boulder, CO, Mental Health Partners</option> <option value="20068">20068-Sherman, TX, Texoma Community Center</option> <option value="20069">20069-Conroe, TX, Tri-County Behavioral Healthcare</option> <option value="20070">20070-Eden Prairie, MN, Nystrom & Associates, Ltd.</option> <option value="20071">20071-Marshall, MN, Western Mental Health Center, Inc.</option> <option value="20072">20072-Phoenix, AZ, Southwest Behavioral & Health Services</option> <option value="20073">20073-Lakeland, FL, Peace River Center</option> <option value="20074">20074-Kent, WA, Valley Cities Counseling & Consultation</option> <option value="20075">20075-Canton, OH, Phoenix Rising Behavioral Healthcare & Recovery</option> <option value="20076">20076-Cleburne, TX, Pecan Valley Centers</option> <option value="20077">20077-Avondale, AZ, Community Bridges, Inc.</option> <option value="20078">20078-Dublin, OH, ViaQuest Clinical Services</option> <option value="20079">20079-Bristol, TN, Frontier Health-Bristol</option> <option value="20080">20080-Tucson, AZ, La Frontera Center, Inc.- East Side Clinic</option> <option value="20081">20081-Oak Ridge, TN, Ridgeview</option> <option value="20082">20082-Boise, ID, Access Behavioral Health Services, Inc.</option> <option value="20083">20083-Duluth, MN, Nystrom & Associates, Ltd.</option> <option value="20084">20084-Pueblo, CO, Health Solutions - Montebello - Pueblo, CO</option> <option value="20086">20086-Fairfax, VA, Neighborhood Health</option> <option value="20087">20087-Reston, VA, Loudon Community Health Center dba HealthWorks for Northern Virginia</option> <option value="20088">20088-Alexandria, VA, Neighborhood Health</option> <option value="20089">20089-Louisville, KY, Seven Counties Services</option> <option value="20090">20090-Olathe, KS, Johnson County Mental Health Center</option> <option value="20091">20091-Texarkana, AR, Southwest Arkansas Counseling and Mental Health Center</option> <option value="20092">20092-Saginaw, MI, Saginaw County Community Mental Health Authority (SCCMHA)</option> <option value="20093">20093-Detroit, MI, CNS Healthcare</option> <option value="20094">20094-Flint, MI, Genessee Health System</option> <option value="20095">20095-Lapeer, MI, Lapeer County Community Mental Health Center</option> <option value="20097">20097-Waterford, MI, CNS Healthcare</option> <option value="20098">20098-Shelby Township, MI, Central Pharmacy- Shelby Township, MI</option> <option value="20100">20100-Southfield, MI, Easter Seals Adult Services</option> <option value="20101">20101-Lansing, MI, Central Pharmacy</option> <option value="20102">20102-Port Huron, MI, St. Clair County Community Mental Health</option> <option value="20104">20104-Jackson, MI, Lifeways CMH- Jackson, MI</option> <option value="20105">20105-Mansfield, OH, Catalyst Life Services- Mansfield, OH</option> <option value="20106">20106-Kendallville, IN, Northeastern Center, Inc.- Kendallville, IN</option> <option value="20107">20107-Columbus, NE, Good Neighbor Community Health Center</option> <option value="20108">20108-Seattle, WA, Asian Counseling and Referral Service</option> <option value="20109">20109-Silver City, NM, Hidalgo Medical Services- Silver City, NM</option> <option value="20110">20110-Bozeman, MT, Western Montana Mental Health Center</option> <option value="20111">20111-Lordsburg, NM, Hidalgo Medical Services- Lordsburg, NM</option> <option value="20112">20112-St. Peters, MO, Advent Medical Group</option> <option value="20113">20113-Holyoke, MA, River Valley Counseling- Holyoke, MA</option> <option value="20114">20114-Greenville, NC, Central Pharmacy - Greenville, NC</option> <option value="20115">20115-Richmond, KY, Bluegrass Regional Mental Health - Richmond, KY</option> <option value="20117">20117-Centralia, WA, Cascade Community Healthcare</option> <option value="20118">20118-Erie, PA, Lakeshore Community Services- Erie, PA</option> <option value="20119">20119-Fort Dodge, IA, Berryhill Mental Health Center- Fort Dodge, IA</option> <option value="20120">20120-Gilbert, AZ, Partners in Recovery, LLC- Gilbert, AZ</option> <option value="20121">20121-Toledo, OH, A Renewed Mind - Toledo, OH</option> <option value="20122">20122-Warsaw, IN, The Bowen Center</option> <option value="20123">20123-Racine, WI, Racine County Human Services Department- Racine, WI</option> <option value="20124">20124-Phoenix, AZ, Terros Health- Phoenix, AZ (51st Ave)</option> <option value="20125">20125-San Marcos, TX, Hill Country MHDD Centers- San Marcos, TX</option> <option value="20126">20126-Chicago, IL, The Thresholds</option> <option value="20127">20127-Conyers, GA, View Point Health</option> <option value="20128">20128-Hartford, CT, Catholic Charities Archdiocese of Hartford</option> <option value="20129">20129-Bend, OR, Deschutes County Health Services</option> <option value="20130">20130-Southaven, MS, Central Pharmacy - Southaven</option> <option value="20133">20133-Alamosa, CO, San Luis Valley Behavioral Health</option> <option value="20134">20134-Charlestown, MA, TILL, Inc.</option> <option value="20136">20136-Mayfield, KY, Four Rivers Behavioral Health, Inc.</option> <option value="20137">20137-Paducah, KY, Four Rivers Behavioral Health, Inc.</option> <option value="20138">20138-Chillicothe, OH, Scioto Paint Valley Mental Health Center</option> <option value="20139">20139-Michigan City, IN, Swanson Center</option> <option value="20140">20140-Warren, OH, Coleman Health Services</option> <option value="20141">20141-Bellingham, WA, Compass Health</option> <option value="20142">20142-Little Rock, AR, Living Hope Southeast</option> <option value="20143">20143-Waukesha, WI, Waukesha County Human Services Department</option> <option value="20144">20144-Hannibal, MO, Mark Twain Behavioral Health</option> <option value="20146">20146-Hartford, CT, Intercommunity, Inc.</option> <option value="20147">20147-Sikeston, MO, Bootheel Counseling Services, Inc.</option> <option value="20148">20148-Phoenix, AZ, Lifewell Behavioral Wellness</option> <option value="20149">20149-Jackson Heights, NY, Catholic Charities Neighborhood Services, Inc.</option> <option value="20151">20151-Middleburg, FL, Clay Behavioral Health Center</option> <option value="20153">20153-West St. Paul, MN, Associated Clinic of Psychology</option> <option value="20154">20154-Winchester, VA, Northwestern Community Services Board</option> <option value="20155">20155-Fort Morgan, CO, Centennial Mental Health Center</option> <option value="20156">20156-Maxwelton, WV, Seneca Health Services, Inc.</option> <option value="20157">20157-Bloomington, IL, Chestnut Family Health Center</option> <option value="20158">20158-Tampa, FL, Northside Behavioral Health Center</option> <option value="20159">20159-Plymouth, NH, Mid-State Health Center</option> <option value="20160">20160-El Dorado, AR, South Arkansas Regional Health Center</option> <option value="20161">20161-Syracuse, NY, Helio Health, Inc.</option> <option value="20162">20162-Kingman, AZ, Mohave Mental Health Clinic</option> <option value="20163">20163-Morristown, TN, Helen Ross McNabb Center</option> <option value="20166">20166-Port Angeles, WA, Peninsula Behavioral Health</option> <option value="20167">20167-Tacoma, WA, Comprehensive Life Resources</option> <option value="20168">20168-Ammon, ID, Rehabilitative Health Services</option> <option value="20169">20169-Detroit, MI, The Health Center @ McKenny</option> <option value="20171">20171-Davenport, IA, Vera French Community Mental Health Center</option> <option value="20172">20172-Lafayette, LA, Acadiana Area Human Services District - Lafayette</option> <option value="20174">20174-Ontario, OR, Lifeways, Inc</option> <option value="20176">20176-Morrisville, VT, Lamoille County Mental Health Services, Inc.</option> <option value="20177">20177-Seattle, WA, Sound (Wallingford)</option> <option value="20178">20178-Perrysburg, OH, Harbor</option> <option value="20179">20179-Bowling Green, OH, Harbor</option> <option value="20180">20180-Springfield, MA, Behavioral Health Network, Inc.</option> <option value="20181">20181-Beckley, WV, FMRS Health Systems, Inc.</option> <option value="20183">20183-Mankato, MN, Open Door Health Center</option> <option value="20184">20184-Greenfield, MA, Clinical & Support Options, Inc.</option> <option value="20185">20185-St. Louis Park, MN, Associated Clinic of Psychology- St. Louis Park, MN (Hwy 7)</option> <option value="20186">20186-Valley Cottage, NY, Mental Health Association of Rockland</option> <option value="20187">20187-Syracuse, NY, Liberty Resources</option> <option value="20188">20188-Manchester, NH, The Mental Health Center of Greater Manchester</option> <option value="20189">20189-Farmville, VA, Crossroads Community Services Board</option> <option value="20190">20190-Fort Lauderdale, FL, Archways - Ft. Lauderdale, FL</option> <option value="20191">20191-Dayton, TN, Volunteer Behavioral Health Care System - Rhea Mental Health Center</option> <option value="20192">20192-Phoenix, AZ, EMPACT Suicide Prevention Center</option> <option value="20193">20193-Toledo, OH, Unison Behavioral Health Group</option> <option value="20195">20195-St. Helens, OR, Columbia Community Mental Health</option> <option value="20196">20196-Huntington, NY, WellLife Network</option> <option value="20198">20198-Lufkin, TX, Burke Center</option> <option value="20199">20199-Springfield, MA, Gandara Mental Health Center</option> <option value="20200">20200-Grants Pass, OR, Options for Southern Oregon</option> <option value="20202">20202-Biddeford, ME, Maine Behavioral Healthcare</option> <option value="20203">20203-Escondido, CA, Mental Health Systems</option> <option value="20204">20204-Mankato, MN, Blue Earth County Human Services</option> <option value="20205">20205-Fort Collins, CO, SummitStone Health Partners</option> <option value="20206">20206-Laredo, TX, Border Region Behavioral Health Center</option> <option value="20208">20208-Weslaco, TX, Tropical Texas Behavioral Health</option> <option value="20211">20211-Hartford, CT, The Wheeler Clinic </option> <option value="20212">20212-Williamsburg, VA, Colonial Behavioral Health</option> <option value="20213">20213-Huntington, WV, Prestera Center</option> <option value="20214">20214-Eugene, OR, Laurel Hill Center</option> <option value="20215">20215-New Port Richey, FL, Baycare Health System</option> <option value="20216">20216-Quincy, MA, Quincy Mental Health Center with the Department of Mental Health</option> <option value="20217">20217-Mansfield Center, CT, United Services, Inc.- Mansfield, CT</option> <option value="20218">20218-Keene, NH, Monadnock Family Services</option> <option value="20219">20219-Tallahassee, FL, Apalachee Center Inc.</option> <option value="20220">20220-Las Vegas, NV, Nevada Behavioral Health System</option> <option value="20221">20221-Philadelphia, PA, The Wedge Recover Centers</option> <option value="20222">20222-Colorado Springs, CO, Diversus Health</option> <option value="20223">20223-Claremont, NH, West Central Behavioral Health </option> <option value="20224">20224-Concord, NH, Riverbend Community Mental Health Center</option> <option value="20225">20225-Phoenix, AZ, Terros Health</option> <option value="20226">20226-Hanover, PA, TrueNorth Wellness Services</option> <option value="20227">20227-Doylestown, PA, Lenape Valley Foundation</option> <option value="20228">20228-Bowling Green, KY, LifeSkills Inc.</option> <option value="20229">20229-Cleveland, OH, Frontline Services</option> <option value="20230">20230-Mandeville, LA, Florida Parishes Human Service Authority</option> <option value="20231">20231-Portland, OR, Cascadia Behavioral Healthcare</option> <option value="20232">20232-Otsego, MN, Nystrom & Associates</option> <option value="20233">20233-Middletown, NY, Access- Supports for Living</option> <option value="20234">20234-Roosevelt, NY, Long Island FQHC, Inc.</option> <option value="20235">20235-Hickory, NC, Catawba Valley Behavioral Health- Hickory, NC</option> <option value="20236">20236-Medford, OR, ColumbiaCare Services</option> <option value="20237">20237-Phoenix, AZ, Lifewell Behavioral Wellness- Phoenix, AZ (Oak)</option> <option value="20238">20238-Philadelphia, PA, Community Council Health Systems- Philadelphia, PA</option> <option value="20239">20239-Irvine, CA, Progeny Psychiatric Group- Irvine, CA</option> <option value="20240">20240-Cleveland, OH, OhioGuidestone</option> <option value="20241">20241-Martinsville, VA, Piedmont CSB - Martinsville, VA</option> <option value="20242">20242-Juneau, AK, SouthEast Alaska Regional Health Consortium (SEARHC)</option> <option value="20243">20243-Lynn, MA, Psychiatric Associates of Lynn- Lynn, MA</option> <option value="20244">20244-Reading, PA, Berks Counseling Center- Reading, PA</option> <option value="20245">20245-Marion, VA, Mount Rogers Community Services Board</option> <option value="20246">20246-Mason City, IA, Prairie Ridge Integrated Behavioral Healthcare</option> <option value="20248">20248-Elk Grove Village, IL, Kenneth Young Center</option> <option value="20249">20249-Mesa, AZ, Community Bridges Inc</option> <option value="20250">20250-Medford, OR, Options for Southern Oregon</option> <option value="20251">20251-Evansville, IN, Midwest Behavioral Health</option> <option value="20252">20252-Ft. Oglethorpe, GA, Lookout Mountain Community Services - LaFayette, GA</option> <option value="20253">20253-Bennington, VT, United Counseling Service, Inc.</option> <option value="20254">20254-Portage, IN, Porter-Starke Services </option> <option value="20255">20255-Nacogdoches, TX, Burke Center</option> <option value="20256">20256-Ammon, ID, Pearl Health Clinic PLLC</option> <option value="20257">20257-Lincoln, NE, Bluestem Health- Lincoln, NE</option> <option value="20258">20258-Crossville, TN, Volunteer Behavioral Health -Cumberland Mountain Mental Health</option> <option value="20259">20259-Worcester, MA, Community Healthlink, Inc.</option> <option value="20260">20260-Corpus Christi, TX, Neuces Center for Mental Health and Intellectual Disabilities </option> <option value="20261">20261-Ashland, OH, Appleseed Community Mental Health Center</option> <option value="20262">20262-Texas City, TX, Gulf Coast Center</option> <option value="20263">20263-Hammond, IN, Regional Mental Health Center</option> <option value="20265">20265-Charlottesville, VA, Region Ten Community Services Board</option> <option value="20266">20266-Jasper, IN, LifeSpring Health Systems</option> <option value="20267">20267-Mesa, AZ, Central Pharmacy</option> <option value="20268">20268-Arlington, VA, Arlington Community Services Board</option> <option value="20269">20269-Florence, KY, NorthKey Community Care</option> <option value="20270">20270-Monessen, PA, Southwestern Pennsylvania Human Services (SPHS)</option> <option value="20271">20271-Gary, IN, Porter-Starke Services, Inc. </option> <option value="20272">20272-Farmington, MO, Great Mines Health Center</option> <option value="20273">20273-Portland, ME, Maine Behavioral Healthcare</option> <option value="20274">20274-Tucson, AZ, Wellbeing Institute </option> <option value="20275">20275-Roseburg, OR, Adapt d/b/a Compass Behavioral Health</option> <option value="20277">20277-New Braunfels, TX, Comal County Mental Health Center</option> <option value="20278">20278-Tucson, AZ, COPE Community Services Inc</option> <option value="20279">20279-Tucson, AZ, Community Partners Integrated Healthcare Inc</option> <option value="20280">20280-Galesburg, IL, Bridgeway</option> <option value="20281">20281-Slidell, LA, Florida Parish Human Services Authority</option> <option value="20282">20282-St. Paul, MN, Natalis Counseling and Psychology Solutions</option> <option value="20283">20283-Spokane, WA, 1st Avenue Pharmacy, Inc</option> <option value="20284">20284-Worcester, MA, Behavioral Healthcare Services</option> <option value="20285">20285-Beaverton, OR, Life Works Northwest - Beaverton OR</option> <option value="20286">20286-Brooklyn, NY, The Jewish Board-Brooklyn NY</option> <option value="20287">20287-Phoenix, AZ, Southwest Network(Osborn)-Phoenix AZ</option> <option value="20288">20288-Punta Gorda, FL, Charlotte Behavioral Health Care-Punta Gorda, FL</option> <option value="20289">20289-San Francisco, CA, Westside Community Services-San Francisco, CA</option> <option value="20291">20291-Austintown, OH, On Demand</option> <option value="20292">20292-Billings, MT, Montana Psychiatry</option> <option value="20293">20293-St Johnsbury, VT, Northeast Kingdom Human Services</option> <option value="20294">20294-Pontiac, MI, EasterSeals Michigan</option> <option value="20295">20295-Washington, IN, Samaritan Center</option> <option value="20296">20296-Troy, NY, Unity House of Troy</option> <option value="20297">20297-Phoenix, AZ, Southwest Network(Saguaro)</option> <option value="20298">20298-Waterbury, CT, Wheeler Clinic</option> <option value="20300">20300-Derby, VT, Northeast Kingdom Human Services, Inc.</option> <option value="20301">20301-Milford, MA, Riverside Community Care</option> <option value="20302">20302-Albany, NY, Albany County Department of Mental Health</option> <option value="20303">20303-Payette, ID, Valley Family Health Care</option> <option value="20304">20304-Sioux City, IA, Siouxland Mental Health Center</option> <option value="20305">20305-Dublin, OH, Syntero-Dublin,OH</option> <option value="20306">20306-Kenosha, WI, Kenosha Human Development</option> <option value="20307">20307-Bucyrus, OH, Community Counseling Services, inc.</option> <option value="20308">20308-St Paul, MN, Accord</option> <option value="20309">20309-Richmond, IN, Centerstone of Indiana - Richmond, IN</option> <option value="20310">20310-Hartford, CT, The Village for Families & Children inc. - Hartford, CT</option> <option value="20311">20311-Oceanside, CA, Mental Health Systems, Inc - Oceanside, CA</option> <option value="20313">20313-Phoenix, AZ, Community Partners Integrated Healthcare Inc. - Phoenix, AZ</option> <option value="20314">20314-McMinnville, OR, Yamhill County Health and Human Services - McMinnville, OR</option> <option value="20315">20315-Appleton, WI, Catalpa Health - Appleton, WI</option> <option value="20317">20317-Longview, TX, Community Healthcore- Longview, TX</option> <option value="20319">20319-Franklin, IN, Adult & Child Mental Health Center Incorporated - Indianapolis, IN</option> <option value="20320">20320-Santa Fe Springs, CA, Pacific Clinics - Santa Fe Springs, CA</option> <option value="20321">20321-Phoenix, AZ, Lifewell Behavioral Wellness - Phoenix, AZ (Desert Cove)</option> <option value="20324">20324-Phoenix, AZ, Southwest Network (Estrella Vista) - Phoenix, AZ</option> <option value="20325">20325-Chelsea, MA, North Suffolk Mental Health Association, Inc. - Chelsea, MA</option> <option value="20327">20327-Fremont, NE, Good Neighbor Community Health Center - Fremont, NE</option> <option value="20328">20328-Chicago Heights, IL, Grand Prairie Services - Chicago Heights, IL</option> <option value="20329">20329-Gilbert, AZ, Resilient Health - Gilbert, AZ</option> <option value="20330">20330-Portland, OR, Wallace Medical Concern- Portland, OR</option> <option value="20331">20331-Watertown, NY, Children's Home of Jefferson County- Watertown, NY</option> <option value="20332">20332-Lexington, KY, Beaumont Behavioral Health (Monarch)-Lexington, KY</option> <option value="20333">20333-Phoenix, AZ, District Medical Group (CRS)- Phoenix, AZ</option> <option value="20334">20334-Front Royal, VA, Northwestern Community Services Board - Winchester, VA</option> <option value="20335">20335-Santee, CA, Mental Health Systems, Inc- Santee, CA</option> <option value="20336">20336-Somerset, PA, Bedford Somerset DBHS- Somerset, PA</option> <option value="20337">20337-Merrillville, IN, Regional Mental Health Center (Borto)- Merrillville, IN</option> <option value="20338">20338-Dixon, IL, Sinnissippi Centers- Dixon, IL</option> <option value="20340">20340-Alma, MI, Gratiot Integrated Health Network- Alma, MI</option> <option value="20341">20341-St Louis, MO, Assisted Recovery Centers of America- St. Louis, MO</option> <option value="20342">20342-Hanford, CA, Kings View Corporation- Hanford, CA</option> <option value="20343">20343-Sewell, NJ, Acenda Integrated Health- Sewell, NJ</option> <option value="20345">20345-Columbus, GA, New Horizons Behavioral Health CSB- Columbus, GA</option> <option value="20348">20348-Sellersville, PA, Penn Foundation, Inc.- Sellersville, PA</option> <option value="20349">20349-Phoenix, AZ, Valle del Sol- Phoenix, AZ </option> <option value="20350">20350-Coos Bay, OR, Coos Health & Wellness- Coos Bay, OR</option> <option value="20351">20351-Coal Grove, OH, Shawnee Family Health Center- Coal Grove, OH</option> <option value="20352">20352-Ypsilanti, MI, Washtenaw County Community Mental Health</option> <option value="20354">20354-Crestview, FL, Bridgeway Center- Crestview, FL</option> <option value="20355">20355-Raytown, MO, ReDiscover- Raytown, MO (Blue Ridge Blvd)</option> <option value="20357">20357-Erie, PA, Stairways Behavioral Health- Erie, PA</option> <option value="20358">20358-Janesville, WI, Rock County Human Services Department- Janesville, WI</option> <option value="20359">20359-Douglasville, GA, Douglas County Community Services Board- Douglasville, GA</option> <option value="20360">20360-Westminster, MD, Access Carroll Integrated Healthcare - Westminster, MD</option> <option value="20361">20361-Maitland, FL, Florida Behavioral Health - Maitland, FL</option> <option value="20362">20362-Crowley, LA, Acadiana Crowley Behavioral Health Clinic- Crowley, LA</option> <option value="20363">20363-Tucson, AZ, Community Partners Integrated Healthcare (Desert Rose) - Tucson, AZ</option> <option value="20364">20364-Scottsburg, IN, LifeSpring Health Systems- Scottsburg, IN</option> <option value="20365">20365-Tucson, AZ, COPE Community Services, Inc.- Tucson, AZ (E Lakeside Pkwy)</option> <option value="20366">20366-Harvard, IL, Community Health Partnership of IL - Harvard, IL</option> <option value="20367">20367-Noblesville, IN, Aspire Indiana Behavioral Health System- Noblesville, IN</option> <option value="20368">20368-Newport, RI, East Bay Community Action Program- Newport, RI</option> <option value="20369">20369-Miami, FL, Fellowship House- Miami, FL</option> <option value="20372">20372-Portland, ME, Spurwink Services- Portland, ME</option> <option value="20373">20373-Sandy, OR, Clackamas County (Sandy Behavioral Health Center)- Sandy, OR</option> <option value="20374">20374-Indianapolis, IN, Adult & Child Mental Health Center (Downtown)- Indianapolis, IN</option> <option value="20375">20375-Chico, CA, Butte County Department of Behavioral Health- Chico, CA</option> <option value="20377">20377-Connersville, IN, Centerstone of Indiana- Connersville, IN</option> <option value="20378">20378-Fresno, CA, Mental Health Systems, Inc- Fresno, CA</option> <option value="20379">20379-Southgate, MI, The Guidance Center- Southgate, MI</option> <option value="20380">20380-New Britain, CT, Wheeler Clinic- New Britain, CT</option> <option value="20381">20381-Kirksville, MO, Mark Twain Behavioral Health - Kirksville, MO</option> <option value="20382">20382-Santa Barbara, CA, Santa Barbara County Department of Behavioral Health- Santa Barbara, CA</option> <option value="20383">20383-San Diego, CA, Pacific Coast Psychiatric Associates, Inc. (Carmel Valley)- San Diego, CA</option> <option value="20384">20384-Alexandria, LA, Central Louisiana Human Services District- Alexandria, LA</option> <option value="20385">20385-Sacramento, CA, Turning Point Community Programs- Sacramento, CA</option> <option value="20386">20386-Beaverton, OR, Central Pharmacy - Beaverton, OR</option> <option value="20387">20387-Lake Mary, FL, Caya Health - Lake Mary, FL</option> <option value="20389">20389-Phoenix, AZ, Valleywise Health McDowell</option> <option value="20390">20390-Las Vegas, NV, UMC HIV/Hepatitis C Wellness Center - Las Vegas, NV</option> <option value="20391">20391-Bryn Mawr, PA, Lower Merion Counseling Services-Bryn Mawr, PA</option> <option value="20392">20392-Monroe, LA, Northeast Delta Human Services Authority- Monroe, LA</option> <option value="20393">20393-Mesa, AZ, Chicanos Por La Causa, Inc.- Mesa, AZ</option> <option value="20394">20394-Clermont, FL, LifeStream Behavioral Center - Clermont, FL</option> <option value="20395">20395-Augusta, ME, AngleZ Behavioral Health Services- Augusta, ME</option> <option value="20396">20396-Yuma, AZ, Horizon Health & Wellness- Yuma, AZ (E 40th St)</option> <option value="20398">20398-Las Cruces, NM, Border Area Mental Health Services - Las Cruces, NM</option> <option value="20399">20399-Chandler, AZ, Southwest Network (San Tan)- Chandler, AZ</option> <option value="20400">20400-Bedford, VA, Horizon Behavioral Health- Bedford, VA</option> <option value="20401">20401-Gloversville, NY, The Family Counseling Center- Gloversville, NY</option> <option value="20402">20402-Imperial, CA, Sun Valley Behavioral Medical Center- Imperial, CA</option> <option value="20403">20403-Indianapolis, IN, Aspire Indiana Behavioral Health System- Indianapolis, IN</option> <option value="20404">20404-Phoenix, AZ, Connections Health Solutions - Phoenix, AZ</option> <option value="20405">20405-Santa Ana, CA, Sensible Care, LLC - Santa Ana, CA</option> <option value="20406">20406-Stanton, MI, Montcalm Care Network - Stanton, MI</option> <option value="20407">20407-Astoria, OR, Clatsop Behavioral Healthcare- Astoria, OR</option> <option value="20409">20409-Petersburg, VA, District 19 Community Services Board - Petersburg, VA</option> <option value="20411">20411-Winona, MN, Hiawatha Valley Mental Health Center Inc.- Winona, MN</option> <option value="20412">20412-Chapel Hill, NC, Freedom House Recovery Center- Chapel Hill, NC</option> <option value="20413">20413-Pearland, TX, Texas Behavioral Health- Pearland, TX</option> <option value="20415">20415-Hope Valley, RI, Wood River Health - Hope Valley, RI</option> <option value="20416">20416-San Angelo, TX, La Esperanza Clinic, Inc. (E 31 St) - San Angelo, TX</option> <option value="20417">20417-Pomona, CA, Tri-City Mental Health Services- Pomona, CA</option> <option value="20418">20418-Holland, MI, Community Mental Health of Ottawa County- Holland, MI</option> <option value="20421">20421-Brooklyn, NY, Catholic Charities Brooklyn and Queens- Brooklyn, NY</option> <option value="20422">20422-Lee's Summit, MO, Central Pharmacy - Lee's Summit, MO</option> <option value="20423">20423-Springfield, MA, Clinical & Support Options- Springfield, MA</option> <option value="20424">20424-Lebanon, TN, Volunteer Behavioral Health Care System - Lebanon, TN</option> <option value="20426">20426-Huron, SD, Community Counseling Services- Huron, SD</option> <option value="20427">20427-Summersville, WV, Seneca Health Services, Inc.- Summersville, WV</option> <option value="20428">20428-Bullhead City, AZ, Southwest Behavioral & Health Services- Bullhead City, AZ</option> <option value="20429">20429-Columbus, OH, North Community Counseling Centers (Westgate)- Columbus, OH</option> <option value="20431">20431-Martinsburg, WV, EastRidge Health Systems- Martinsburg, WV</option> <option value="20432">20432-Waterbury, CT, CNV HELP- Waterbury, CT</option> <option value="20434">20434-Shreveport, LA, Seedlinks Behavior Management LLC - Shreveport, LA</option> <option value="20435">20435-Sulphur, LA, Imperial Calcasieu Sulphur Behavioral Health Clinic - Sulphur, LA</option> <option value="20436">20436-Newport, OR, Lincoln County HHS- Newport, OR</option> <option value="20437">20437-Freeport, NY, South Shore Child Guidance Association, Inc.- Freeport, NY</option> <option value="20438">20438-Glendale, AZ, Sahara Behavioral Health</option> <option value="20439">20439-Knox, IN, Porter-Starke Services</option> <option value="20440">20440-San Luis Obispo, CA, San Luis Obispo County Behavioral Health Department</option> <option value="20442">20442-Denton, TX, Denton County MHMR Center- Denton, TX</option> <option value="20443">20443-Forest City, NC, Family Preservation Services- Rutherfordton, NC</option> <option value="20444">20444-Poughkeepsie, NY, Family Services, Inc./ Hudson Valley Mental Health- Poughkeepsie, NY</option> <option value="20446">20446-Copiague, NY, New Horizon Counseling Center- Copiague, NY</option> <option value="20448">20448-Gallatin, TN, Volunteer Behavioral Health Care System - Gallatin, TN</option> <option value="20449">20449-Morrisonville, NY, Behavioral Health Services North, Inc.- Morrisonville, NY</option> <option value="20450">20450-Tucson, AZ, COPE Community Services, Inc</option> <option value="20451">20451-Tulsa, OK, Crossroads Counseling</option> <option value="20452">20452-Aurora, IL, Association for Individual Development (AID) Behavioral Health</option> <option value="20453">20453-Queensbury, NY, Behavioral Health Services North, Inc</option> <option value="20455">20455-Boston, MA, Bay Cove Human Services</option> <option value="20456">20456-Pewaukee, WI, Alay Health Team- Pewaukee, WI</option> <option value="20457">20457-Bradford, PA, The Guidance Center- Bradford, PA</option> <option value="20458">20458-Griswold, CT, United Community and Family Services- Griswold, CT</option> <option value="20459">20459-Marshalltown, IA, Center Associates- Marshalltown, IA</option> <option value="20460">20460-Carney's Point, NJ, Healthcare Commons Inc.- Carneys Point, NJ</option> <option value="20461">20461-Millville, NJ, Cumberland County Guidance Center- Millville, NJ</option> <option value="20462">20462-Huntington, IN, The Bowen Center - Huntington, IN</option> <option value="20463">20463-Lincoln, NE, Pine Lake Behavioral Health - Lincoln, NE</option> <option value="20464">20464-Colorado Springs, CO, Achieve Whole Recovery - Colorado Springs, CO</option> <option value="20465">20465-Lincoln, NE, CenterPointe (South Street Project) - Lincoln, NE</option> <option value="20467">20467-Indianapolis, IN, Central Pharmacy</option> <option value="20468">20468-Indianapolis, IN, Community Health Network- Indianapolis, IN</option> <option value="20470">20470-Findlay, OH, Family Resource Center - Findlay, OH</option> <option value="20471">20471-Exeter, NH, Seacoast Mental Health Center - Exeter, NH</option> <option value="20472">20472-Weatherford, TX, Pecan Valley Centers - Weatherford, TX</option> <option value="20473">20473-Aurora, CO, Mile High Psychiatry - Aurora, CO</option> <option value="20474">20474-Las Vegas, NV, The Center LGBTQ+- Las Vegas, NV</option> <option value="20475">20475-Rockford, IL, Rosecrance Harrison Campus - Rockford IL</option> <option value="20476">20476-Colorado Springs, CO, Mentally Strong - Colorado Springs, CO</option> <option value="20477">20477-Kingsport, TN, Frontier Health - Kingsport, TN</option> <option value="20478">20478-Addison, TX, Preston Hollow Psychiatry Group - Addison, TX</option> <option value="20479">20479-Washington, PA, The CARE Center - Washington, PA</option> <option value="20480">20480-Covington, KY, NorthKey Community Care - Covington KY</option> <option value="20481">20481-Peoria, IL, Heartland Health Services East Bluff- Peoria, IL</option> <option value="20482">20482-Syracuse, NY, Compassionate Family Medicine- Syracuse, NY</option> <option value="20483">20483-Austin, TX, New Vision Psychiatry and Wellness- Austin, TX</option> <option value="20484">20484-Hamilton, OH, Butler Behavioral Health Services, Inc. - Hamilton, OH</option> <option value="20486">20486-Galloway, NJ, Center for Family Services - Absecon NJ</option> <option value="20487">20487-Detroit, MI, Neighborhood Service Organization (DHHC)- Detroit, MI</option> <option value="20488">20488-Leesburg, VA, HealthWorks for Northern Virginia - Leesburg, VA</option> <option value="20489">20489-Gastonia, NC, Monarch- Gastonia, NC</option> <option value="20490">20490-Clinton Township, MI, Macomb County Community Mental Health ( North) - Clinton Township, MI</option> <option value="20491">20491-Ithaca, NY, Tompkins County Mental Health- Ithaca, NY</option> <option value="20492">20492-Fort Worth, TX, MHMR of Tarrant County (Penn Square) - Ft Worth, TX</option> <option value="20494">20494-Price, UT, Four Corners Community Behavioral Health- Price, UT</option> <option value="20496">20496-Framingham, MA, Advocates, Inc.- Framingham, MA</option> <option value="20497">20497-El Paso, TX, La Mente Behavioral Health (Montana Ave.) - El Paso, TX</option> <option value="20498">20498-Hope, AR, Southwest Arkansas Counseling Mental Health Center-Hope, AR</option> <option value="20499">20499-Bridgeport, WV, Transformations Care Network- Bridgeport, WV</option> <option value="20500">20500-Worcester, MA, Open Sky Community Services - Worcester, MA</option> <option value="20501">20501-Ontario, OR, Valley Family Health (Pharmacy Location)- Ontario, OR</option> <option value="20502">20502-Fort Worth, TX, MHMR of Tarrant County (Northwest Clinic) - Fort Worth, TX</option> <option value="20503">20503-North Richland Hills, TX, MHMR of Tarrant County - North Richland Hills, TX</option> <option value="20504">20504-Jackson, TN, Quinco Mental Health Center - Bolivar, TN</option> <option value="20505">20505-Shelby, NC, Monarch- Shelby, NC</option> <option value="20506">20506-Tucson, AZ, La Frontera Center-Tucson, AZ (Main)</option> <option value="20507">20507-Searcy, AR, PrimeCare Medical Clinic-Searcy, AR</option> <option value="20508">20508-Murray, UT, Cedar Psychiatry - Murray, UT</option> <option value="20509">20509-Wiscasset, ME, Wiscasset Family Health- Wiscasset, ME</option> <option value="20513">20513-Williamsport, PA, Community Services Group- Williamsport, PA</option> <option value="20514">20514-Fort Worth, TX, MHMR of Tarrant County (Circle Drive) - Fort Worth, TX</option> <option value="20515">20515-Greenfield, MA, Valley Medical Group - Greenfield, MA</option> <option value="20516">20516-Baton Rouge, LA, North Baton Rouge Behavioral Health- Baton Rouge, LA</option> <option value="20518">20518-West Branch, MI, AuSable Valley Community Mental Health Authority</option> <option value="20519">20519-Arlington, TX, MHMR of Tarrant County </option> <option value="20520">20520-San Francisco, CA, Central Pharmacy - San Francisco, CA</option> <option value="20521">20521-Tucson, AZ, Sahara Behavioral Health (Tucson) - Tucson - AZ</option> <option value="20522">20522-Leominster, MA, Community Healthlink- Leominster, MA</option> <option value="20523">20523-Sioux City, IA, Dr. Dean & Associates- Sioux City, IA</option> <option value="20524">20524-West Springfield, MA, Center for Human Development</option> <option value="20526">20526-Las Vegas, NV, Human Behavior Institute- Las Vegas, NV</option> <option value="20527">20527-Albuquerque, NM, Optum Care (Journal Center)-Albuquerque, NM</option> <option value="20528">20528-Littleton, NH, Ammonoosuc Community Health Services, Inc. - Littleton, NH</option> <option value="20530">20530-Peru, IN, Central Pharmacy </option> <option value="20532">20532-Grand Island, NE, Human Behavior Institue- Las Vegas, NV</option> <option value="20533">20533-Batesville, IN, Community Mental Health Center</option> <option value="20534">20534-Mesa, AZ, Valle Del Sol (East Valley)- Mesa, AZ</option> <option value="20535">20535-Pleasant Valley, WV, Valley HealthCare System (Valley Comprehensive Community Health Center INC) - Morgantown, WV </option> <option value="20537">20537-Monsey, NY, Achieve Behavioral Health (A Division of Bikur Cholim)- Monsey, NY</option> <option value="20540">20540-Great Bend, KS, The Center for Counseling and Consultation- Great Bend, KS</option> <option value="20541">20541-Oregon City, OR, Clackamas County Mental Health</option> <option value="20542">20542-Bristol, CT, Wheeler Clinic- Bristol, CT</option> <option value="20543">20543-Riverside, RI, East Bay Community Action Program- Riverside, RI</option> <option value="20544">20544-Gualala, CA, Redwood Coast Medical Services - Gualala, CA</option> <option value="20545">20545-Prescott Valley, AZ, Polara Health (Windsong)</option> <option value="20546">20546-Baxter, MN, Nystrom & Associates, Ltd- Baxter, MN</option> <option value="20547">20547-Sartell, MN, Nystrom & Associates, Ltd- Sartell, MN</option> <option value="20548">20548-Phoenix, AZ, Lifewell (Mitchell) - Phoenix, AZ</option> <option value="20549">20549-Nampa, ID, Acacia Wellness Center - Nampa, ID</option> <option value="20550">20550-Anaheim, CA, Korean Community Services- Anaheim, CA</option> <option value="20551">20551-Buena Park, CA, Korean Community Services (Commonwealth)-Buena Park, CA</option> <option value="20552">20552-Rapid City, SD, Manlove Brain and Body Health- Rapid City, SD</option> <option value="20553">20553-Maryville, TN, Helen Ross McNabb- Maryville, TN</option> <option value="20555">20555-New Castle, PA, Human Services Center- New Castle, PA</option> <option value="20556">20556-Owensboro, KY, RiverValley Behavioral Health- Owensboro, KY</option> <option value="20557">20557-Omaha, NE, Omaha Insomnia and Psychiatric Services</option> <option value="20558">20558-Louisville, KY, Seven Counties Services - Louisville, KY (914 E. Broadway)</option> <option value="20559">20559-Ansonia, CT, BHcare- Ansonia, CT</option> <option value="20560">20560-St. Joseph, MO, The Center, a Samaritan Center- St. Joseph, MO</option> <option value="20561">20561-Torrington, CT, Community Health and Wellness Center of Greater Torrington</option> <option value="20562">20562-Redding, CA, North American Mental Health Services (Pharmacy Location)- Redding, CA</option> <option value="20563">20563-Joliet, IL, Will County Community Health Center</option> <option value="20564">20564-Stamford, CT, Community Health Center, Inc. (CHC)- Stamford, CT</option> <option value="20565">20565-Brooklyn, NY, Services for the Underserved- Brooklyn, NY</option> <option value="20566">20566-Tempe, AZ, Be Well Family Care - Phoenix, AZ</option> <option value="20568">20568-Garden City, KS, Compass Behavioral Health- Garden City, KS</option> <option value="20570">20570-Warren, PA, Journey Health System - Warren, PA</option> <option value="20571">20571-Pine Bluff, AR, Southeast Arkansas Behavioral Health System- Pine Bluff, AR</option> <option value="20573">20573-Rochester, NY, Helio Health, Inc.- Rochester, NY</option> <option value="20574">20574-Visalia, CA, Tulare County Health and Human Services Agency Department of Mental Health</option> <option value="20575">20575-McAllen, TX, Jose Igoa M.D.- McAllen, TX</option> <option value="20576">20576-Shreveport, LA, Northwest Louisiana Human Services District</option> <option value="20577">20577-Maryville, IL, Chestnut Health Systems - Maryville, IL</option> <option value="20578">20578-Defiance, OH, Maumee Valley Guidance Center</option> <option value="20579">20579-Canon City, CO, Solvista Health</option> <option value="20581">20581-Westland, MI, Hegira Health Inc.- Westland, MI</option> <option value="20583">20583-Ottumwa, IA, Southern Iowa Mental Health Center- Ottumwa, IA(BH)</option> <option value="20584">20584-Van Buren, AR, Western Arkansas Counseling and Guidance Center-Van Buren, AR</option> <option value="20585">20585-Lawrenceville, IL, Lawrence County Health Department Behavior Health Division - Lawrenceville, IL</option> <option value="20586">20586-Zanesville, OH, Allwell Behavioral Health Services- Zanesville, OH</option> <option value="20588">20588-Edina, MN, PsyFi TMS- Edina, MN</option> <option value="20589">20589-San Antonio, TX, Phoenix Mental Health- San Antonio, TX</option> <option value="20590">20590-Palm Beach Gardens, FL, Henderson Behavioral Health - Palm Beach Gardens, FL</option> <option value="20592">20592-Raleigh, NC, Southlight Healthcare-Raleigh, NC</option> <option value="20612">20612-Valdosta, GA, Legacy Behavioral Health Services - Valdosta, GA</option> <option value="20616">20616-Tifton, GA, Legacy Behavioral Health Services - Tifton, GA</option> </select> <span class="field-validation-valid" data-valmsg-for="Pharmacy_Key" data-valmsg-replace="true"></span> </div> </div> <fieldset> <legend>Center Information</legend> <div class="row"> <div class="medium-12 columns"> <label for="ClinicName">Center Name</label> <input class="text-box single-line" data-val="true" data-val-length="The field Center Name must be a string with a maximum length of 255." data-val-length-max="255" data-val-required="Center Name is required." id="ClinicName" maxlength="255" name="ClinicName" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="ClinicName" data-valmsg-replace="true"></span> </div> </div> <div class="row"> <div class="medium-8 columns"> <label for="OfficeAddress1">Center Address Line 1</label> <input class="text-box single-line" data-val="true" data-val-required="Center Address Line 1 is required." id="OfficeAddress1" name="OfficeAddress1" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="OfficeAddress1" data-valmsg-replace="true"></span> </div> </div> <div class="row"> <div class="medium-8 columns"> <label for="OfficeAddress2">Center Address Line 2</label> <input class="text-box single-line" id="OfficeAddress2" name="OfficeAddress2" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="OfficeAddress2" data-valmsg-replace="true"></span> </div> </div> <div class="row"> <div class="medium-4 columns"> <label for="City">City</label> <input class="text-box single-line" data-val="true" data-val-length="The field City must be a string with a maximum length of 80." data-val-length-max="80" data-val-required="City is required." id="City" maxlength="80" name="City" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="City" data-valmsg-replace="true"></span> </div> <div class="medium-4 columns"> <label for="State">State</label> <select data-val="true" data-val-length="The field State must be a string with a maximum length of 2." data-val-length-max="2" data-val-required="State is required." id="State" name="State"><option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="DC">District Of Columbia</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</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="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> <span class="field-validation-valid" data-valmsg-for="State" data-valmsg-replace="true"></span> </div> <div class="medium-4 columns"> <label for="ZipCode">Zip Code</label> <input class="text-box single-line" data-val="true" data-val-length="The field Zip Code must be a string with a maximum length of 10." data-val-length-max="10" data-val-required="Zip Code is required." id="ZipCode" maxlength="10" name="ZipCode" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="ZipCode" data-valmsg-replace="true"></span> </div> </div> <div class="row"> <div class="medium-6 columns"> <label for="Phone">Phone</label> <input class="text-box single-line" data-val="true" data-val-length="The field Phone must be a string with a maximum length of 14." data-val-length-max="14" id="Phone" maxlength="14" name="Phone" type="tel" value="" /> <span class="field-validation-valid" data-valmsg-for="Phone" data-valmsg-replace="true"></span> </div> <div class="medium-6 columns"> <label for="Fax">Fax</label> <input class="text-box single-line" data-val="true" data-val-length="The field Fax must be a string with a maximum length of 14." data-val-length-max="14" id="Fax" maxlength="14" name="Fax" type="tel" value="" /> <span class="field-validation-valid" data-valmsg-for="Fax" data-valmsg-replace="true"></span> </div> </div> </fieldset> <fieldset> <legend>Account Information</legend> <div class="row"> <div class="medium-4 columns"> <label for="FirstName">First Name</label> <input class="text-box single-line" data-val="true" data-val-length="The field First Name must be a string with a maximum length of 80." data-val-length-max="80" data-val-required="First Name is required." id="FirstName" maxlength="80" name="FirstName" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="FirstName" data-valmsg-replace="true"></span> </div> <div class="medium-4 columns"> <label for="LastName">Last Name</label> <input class="text-box single-line" data-val="true" data-val-length="The field Last Name must be a string with a maximum length of 80." data-val-length-max="80" data-val-required="Last Name is required." id="LastName" maxlength="80" name="LastName" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="LastName" data-valmsg-replace="true"></span> </div> <div class="medium-4 columns"> <label for="JobTitle">Title</label> <input class="text-box single-line" data-val="true" data-val-length="The field Title must be a string with a maximum length of 40." data-val-length-max="40" data-val-required="Title is required." id="JobTitle" maxlength="40" name="JobTitle" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="JobTitle" data-valmsg-replace="true"></span> </div> </div> <div class="row"> <div class="large-12 columns"> <label for="EmailAddress">Email Address</label><label style='color:red'>(corporate email address only)</label> <input class="text-box single-line" data-val="true" data-val-length="The field Email Address must be a string with a maximum length of 255." data-val-length-max="255" data-val-regex="Please enter a valid Email Address." data-val-regex-pattern="^([a-zA-Z0-9_\-\.]+)@((\[[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\.)|(([a-zA-Z0-9\-]+\.)+))([a-zA-Z]{2,10}|[0-9]{1,3})(\]?)$" data-val-required="Email Address is required." id="EmailAddress" maxlength="255" name="EmailAddress" type="email" value="" /> <span class="field-validation-valid" data-valmsg-for="EmailAddress" data-valmsg-replace="true"></span> </div> </div> <div class="row"> <div class="medium-6 columns"> <label for="Password">Password</label> <input class="text-box single-line password" data-val="true" data-val-length="Password must be between 8 and 100 characters long." data-val-length-max="100" data-val-length-min="8" data-val-regex="Password must be at least 8 characters and contain at least one of each of the following: uppercase, lowercase, number, and special character." data-val-regex-pattern="^(?:(?=.*[a-z])(?:(?=.*[A-Z])(?=.*[\d\W])(?=.*\W)(?=.*\d))(?=.*\W)(?=.*[A-Z])(?=.*\d)).{8,}$" data-val-required="Password is required." id="Password" maxlength="100" name="Password" type="password" /> <span class="field-validation-valid" data-valmsg-for="Password" data-valmsg-replace="true"></span> </div> <div class="medium-6 columns"> <label for="ConfirmPassword">Confirm Password</label> <input class="text-box single-line password" data-val="true" data-val-equalto="Password and confirmation password do not match." data-val-equalto-other="*.Password" data-val-required="Confirm Password is required." id="ConfirmPassword" name="ConfirmPassword" type="password" /> <span class="field-validation-valid" data-valmsg-for="ConfirmPassword" data-valmsg-replace="true"></span> </div> </div> <fieldset> <legend>Application Access</legend> <div class="row"> <div class="medium-3 columns"> <label for="NetRx">NetRx</label> <input data-val="true" data-val-required="NetRx is required." id="netRxTrue" name="NetRx" type="radio" value="true" /> <label for="netRxTrue">Yes</label> <input checked="checked" id="netRxFalse" name="NetRx" type="radio" value="false" /> <label for="netRxFalse">No</label> <div id="elink-access" class="hide"> <label>  <input data-val="true" data-val-required="The eLink field is required." id="eLink" name="eLink" type="checkbox" value="true" />  eLink Access <br /><font size="-2" style="margin-left: 25px;">(Genoa CMC Users Only)</font></label> </div> </div> <div class="medium-3 columns"> <label for="SampleManagement">Sample Management</label> <input data-val="true" data-val-required="Sample Management is required." id="sampleManagementTrue" name="SampleManagement" type="radio" value="true" /> <label for="sampleManagementTrue">Yes</label> <input checked="checked" id="sampleManagementFalse" name="SampleManagement" type="radio" value="false" /> <label for="sampleManagementFalse">No</label> <span class="field-validation-valid" data-valmsg-for="SampleManagement" data-valmsg-replace="true"></span> </div> <div class="medium-3 columns"> <label for="MedAnalyzer">MedAnalyzer</label> <input data-val="true" data-val-required="MedAnalyzer is required." id="medAnalyzerTrue" name="MedAnalyzer" type="radio" value="true" /> <label for="medAnalyzerTrue">Yes</label> <input checked="checked" id="medAnalyzerFalse" name="MedAnalyzer" type="radio" value="false" /> <label for="medAnalyzerFalse">No</label> <span class="field-validation-valid" data-valmsg-for="MedAnalyzer" data-valmsg-replace="true"></span> <div id="med-a-role" class="hide"> <label for="MedAnalyzerRoleId">MedAnalyzer Role</label> <select data-val="true" data-val-required="The MedAnalyzer Role field is required." id="MedAnalyzerRoleId" name="MedAnalyzerRoleId"><option selected="selected" value="1">Management</option> <option value="0">Prescriber</option> </select> <div id="npi-number" class="hide"> <label for="NPINumber">Prescriber NPI Number</label> <input class="text-box single-line" id="NPINumber" name="NPINumber" type="text" value="" /> <span class="field-validation-valid" data-valmsg-for="NPINumber" data-valmsg-replace="true"></span> </div> </div> </div> <div class="medium-3 columns"> <label for="MonthlyEmailReport">Monthly Email Report</label> <input data-val="true" data-val-required="Monthly Email Report is required." id="monthlyEmailReportTrue" name="MonthlyEmailReport" type="radio" value="true" /> <label for="monthlyEmailReportTrue">Yes</label> <input checked="checked" id="monthlyEmailReportFalse" name="MonthlyEmailReport" type="radio" value="false" /> <label for="monthlyEmailReportFalse">No</label> <span class="field-validation-valid" data-valmsg-for="MonthlyEmailReport" data-valmsg-replace="true"></span> </div> </div> <div class="row"> <span class="field-validation-valid" data-valmsg-for="NetRx" data-valmsg-replace="true"></span> </div> </fieldset> <div class="row"> <div class="large-12 columns"> <p class="hipaa-text"> <input class="check-box" data-val="true" data-val-required="The HIPAA field is required." id="HIPAA" name="HIPAA" type="checkbox" value="true" /> As a Genoa Online user, I shall comply with applicable provisions of the Health Insurance Portability and Accountability Act of 1996 and regulations there-under as amended from time to time ("HIPAA"). <span class="field-validation-valid" data-valmsg-for="HIPAA" data-valmsg-replace="true"></span> </p> <p> <a target="_blank" href="/Content/Files/Genoa%20Online%20System%20Terms%20of%20Use.pdf">Genoa Online System Terms of Use</a> <br /> <a target="_blank" href="/Content/Files/Genoa%20Website%20Terms%20of%20Use.pdf">Genoa Website Terms of Use</a> </p> </div> </div> </fieldset> <div class="row"> <div class="large-12 columns"> <input href="#dialog-confirm" type="submit" class="button right" value="Register" /> </div> </div> <div id="dialog-confirm" class="modal" style="max-width: 55%;"> <div class="row"> <div class="medium-12 columns"> <h3>Confirm Acknowledgement</h3> <p> <a target="_blank" href="/Content/Files/Genoa%20Online%20System%20Terms%20of%20Use.pdf">Genoa Online System Terms of Use</a> <br /> <a target="_blank" href="/Content/Files/Genoa%20Website%20Terms%20of%20Use.pdf">Genoa Website Terms of Use</a> </p> <p>I hereby agree to comply with the applicable provisions in accordance with the regulations set forth in 45 C.F.R. Parts 160 and 164 issued pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”) and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act set forth in 42 U.S.C. § 17921 et seq. In addition, I shall at all times comply with the provisions of the Privacy and Security Rules applicable to me, including the minimum necessary requirements, which state that protected health information should not be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. The minimum necessary standard requires me to evaluate my practices and enhance safeguards as needed to limit unnecessary or inappropriate access to and disclosure of protected health information. Finally, should my employment be terminated, or a change in position that would make access to Genoa Online and its tools no longer permissible, I agree to notify Genoa immediately of my employment status change.</p> </div> </div> <div class="row"> <div class="medium-12 columns"> <button id="accept">I agree to the foregoing requirements under HIPAA and HITECH conditions, as stated above</button> <button id="decline">I do not agree to the foregoing requirements under HIPAA and HITECH conditions, as stated above <cite>(access will not be granted if this option is selected)</cite></button> </div> </div> </div> <input name="__RequestVerificationToken" type="hidden" value="CfDJ8BhWyswW4JREi_1VaRkt8dznDUFol-EttWv4U8yCVLUxTDcY0tQSjeilUw3QZ-pOkLi0HcGqov-XMrJIGIEez9141GfMA9CtKbpWi71VLDHiQ_gb8el_1IZlL3hSyIhCBeZ2Dhh5ioeMQOStJye1kCI" /><input name="eLink" type="hidden" value="false" /><input name="HIPAA" type="hidden" value="false" /></form> </section> </div> </div> </section> </div> </div> <footer> <div class="row"> <div class="large-12 columns"> <ul class="centered-inline-list"> <li><a target="_blank" href="http://www.genoahealthcare.com/">Home</a></li> <li><a target="_blank" href="http://www.genoahealthcare.com/about-us/">About Us</a></li> <li><a target="_blank" href="http://www.genoahealthcare.com/pharmacy/">Pharmacy</a></li> <li><a target="_blank" href="http://www.genoahealthcare.com/careers/">Careers</a></li> <li><a target="_blank" href="http://www.genoahealthcare.com/contact-us/">Contact Us</a></li> </ul> </div> </div> <div class="row disclaimer"> <div class="large-12 columns"> <ul class="centered-inline-list"> <li>© Genoa Healthcare. All rights reserved.</li> <li><a target="_blank" href="http://www.genoahealthcare.com/website-terms-of-use/">Terms of Use</a></li> <li><a target="_blank" href="http://www.genoahealthcare.com/website-privacy-policy/">Privacy Policy</a></li> <li><a target="_blank" href="http://www.genoahealthcare.com/notice-of-privacy-practices/">Privacy Statement</a></li> </ul> </div> </div> </footer> <script src="/bundles/jquery.js"></script> <script src="/js/Shared/_LayoutBody.js"></script> <script src="/bundles/jqueryval.js"></script> <script src="/bundles/register.js"></script> </body> </html>