PointClickCare Integration request

Before submitting this form, please follow the below steps to request the app activation:

Log in to PointClickCare.
Do one of the following:
Single community: Home > Marketplace > Manage Integrations.
Multi-community: Management Console > Home > Manage Integrations.
Click Activation Request and Complete the following:
Legal Organization Name - Type the legal name for the organization at the time the request is made.
Application - Select Empeon.
Select facilities to activate application - Select the communities in which the application is installed.
Title - Type the title of the authorized requester.
Which email would like to be notified at? - Type email address. This email is used for communication regarding this request.
Requested By -Type the first and surname of the requester. Requester must be an authorized signer for your organization.
Health Care Provider - Type the Health Care Provider name.
Please read and agree to the Terms of Agreement to continue - Read the Terms of Agreement and click Accept.
Click Submit.
An Empeon representative will reach out to you

Please note: There will be a $50 fee per company per month

Name

Email address

Job Title

PointClickCare Org ID

Applicable companies

Please map your PointClickCare facilities

PointClickCare Facility ID	Empeon Company ID

+ Add Facility

Comments

Agreement to Share Data and Liability Disclaimer

By submitting this form and enabling integrations for the specified company, I acknowledge and agree to share the necessary data with the third-party integration provider. I understand that Empeon is not liable for any damages arising from the integration or use of third-party services, and I affirm that I have the authority to act on behalf of the company and ensure proper authorization. While the company will make reasonable efforts to protect the shared data, I acknowledge that no data transmission can be guaranteed as completely secure, and Empeon is not responsible for any unauthorized access, hacking, or security breaches. I also authorize the third-party provider to make any necessary changes to the shared data for the integration process, and I understand that Empeon is not liable for any consequences or damages resulting from those actions. By submitting this form, I confirm my understanding and agreement to these terms.

Fee Agreement

I agree to the one-time implementation fee of $500, and the $50 integration fee per company, billed monthly.