Heaplus Community Partner Application Page 2
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26. HEAplus Community Partner Agreement Contact Person (AHCCCS will send the agreement to this person for
signature):
Name: _____________________________________
Title: ___________________________________
Mailing Address: ________________________________________________________________
Email Address: _________________________________________
Phone Number: ___________________
SITE ADMINISTRATOR
Your HEAplus Site Administrator is the person in your organization who will be responsible for:
•
Creating HEAplus accounts for your staff
•
Resetting HEAplus passwords for your staff
•
Deactivating HEAplus user accounts when staff members leave your employment or move to a new position that
does not use HEAplus
•
Keeping the information for your organization’s locations (sites) current.
7. Please provide the following information for the person who will be your organization’s Site Administrator:
Name: ______________________________________________
Preferred User Name for HEAplus log in: _____________________
Mailing Address: ________________________________________________________________
Email Address: ___________________________
Phone Number: ________________
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Revised 03/10/2017
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