UPMC BU > CloudPages > API Internal Testing Forms > HIPAA Business Associate Contact Form - TEST FORM


      <h2>HIPAA Business Associate Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/hipaa-business-associate-contact-form-api-internal-testing-form" method="post">
         <label>Email</label>
         <input type="text" name="email_address"><br>
         <label>Company Name</label>
         <input type="text" name="company"><br>
         <label>Street Address 1</label>
         <input type="text" name="street_address_1"><br>
         <label>Street Address 2</label>
         <input type="text" name="street_address_2"><br>
         <label>City</label>
         <input type="text" name="city"><br>
         <label>State</label>
         <input type="text" name="state"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br>
         <label>Country</label>
         <input type="text" name="country"><br>
         <label>Phone Number</label>
         <input type="text" name="phone_number"><br>
         <label>D&amp;B Number</label>
         <input type="text" name="db_number"><br><br>

         <label>Business Associate</label><br>
         <select name="business_associate" id="business_associate" multiple>
            <option value="True">Select the box if you or your company, as applicable, either (a) does not have access to UPMC patient information, or (b) is not a Business Associate as defined in the Health Insurance Portability and Accountability Act of 1996 and is therefore not a UPMC Business Associate.</option>
         </select><br><br>
         
         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br><br>
         
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>