Community Staff & Service Partner Registration Form

Community Staff & Service Partner Registration Form
Bluestone Physician Services created the Bluestone Bridge to provide secure, direct communication between families and the patient care team. Users are not allowed to enroll as a group and each user must have an individual account to utilize the Bluestone Bridge. The Nurse Manager, Director of Nursing, or Health Administrator must complete the form. Service Partner’s must supply appropriate documentation to support their need for patient access and validate their employment with that service agency.
Step 1: (New Registration Only)

Go to https://bps.bluestonebridge.com and click the "New User? Create an Account" link then follow the steps to register.

Step 2:

Complete and submit this electronic form within (5) days of registering on the Bluestone Bridge.
Add UserReactivate AccountRemove User
Name*

First NameLast Name
Title*
Email*
example@example.com
If you do not have a company email address, please use firstname.lastname@communitydomain.com

Example: Jane.Doe@happyhome.com

***Personal email addresses may not be used***
This is not a working email addressPreviously used email
Community / Service Agency Name and Code*

Company NameSecurity Code
Community / Service Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Community / Service Agency Phone Number*
Please enter a valid phone number.
Need to add an additional location?
Community / Service Agency Name and Code*

Company NameSecurity Code
Community / Service Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Community / Service Agency Phone Number*
Please enter a valid phone number.
Need to add an additional location?
Community / Service Agency Name and Code*

Company NameSecurity Code
Community / Service Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Community / Service Agency Phone Number*
Please enter a valid phone number.
Need to add an additional location?
Community / Service Agency Name and Code*

Company NameSecurity Code
Community / Service Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Community / Service Agency Phone Number*
Please enter a valid phone number.
Need to add an additional location?
Community / Service Agency Name and Code*

Company NameSecurity Code
Community / Service Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Community / Service Agency Phone Number*
Please enter a valid phone number.
Name of person filling out this form*

NameTitle
Signature*

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: