{"id":11193,"date":"2025-08-21T16:14:11","date_gmt":"2025-08-21T14:14:11","guid":{"rendered":"https:\/\/support.mrdm.com\/?post_type=codman&#038;p=11193"},"modified":"2026-08-27T12:57:34","modified_gmt":"2026-08-27T10:57:34","slug":"aanmeldformulier","status":"publish","type":"codman","link":"https:\/\/support.mrdm.com\/nl\/codman\/codman-connect\/aanmeldprocedure\/aanmeldformulier\/","title":{"rendered":"Aanmeldformulier"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Middels dit aanvraagformulier vraagt u Codman Connect aan voor uzelf en samenwerkende zorginstellingen.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Zodra MRDM dit ingevulde aanvraagformulier ontvangen heeft, stelt MRDM een contract op voor de participerende zorginstellingen. Nadat alle participerende zorginstellingen dit contract hebben ondertekend, wordt Codman Connect geactiveerd.<\/p>\n\n\n<style id=\"wpforms-css-vars-12834\">\n\t\t\t\t#wpforms-12834 {\n\t\t\t\t--wpforms-field-border-size: 2px;\n--wpforms-field-border-radius: 4px;\n--wpforms-field-border-color: #d0d5d9;\n--wpforms-field-border-color-spare: #d0d5d9;\n--wpforms-field-text-color: rgba(0, 0, 0, 0.7);\n--wpforms-label-color: rgba(0, 0, 0, 0.85);\n--wpforms-label-sublabel-color: rgba(0, 0, 0, 0.55);\n--wpforms-button-background-color: #0794ad;\n--wpforms-container-padding: 30px;\n--wpforms-container-border-style: solid;\n--wpforms-container-border-radius: 6px;\n--wpforms-container-border-color: #d0d5d9;\n--wpforms-background-color: #ffffff;\n--wpforms-field-size-input-height: 50px;\n--wpforms-field-size-input-spacing: 20px;\n--wpforms-field-size-font-size: 18px;\n--wpforms-field-size-line-height: 21px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 18px;\n--wpforms-field-size-sublabel-spacing: 10px;\n--wpforms-field-size-icon-size: 1.25;\n--wpforms-label-size-font-size: 18px;\n--wpforms-label-size-line-height: 21px;\n--wpforms-label-size-sublabel-font-size: 16px;\n--wpforms-label-size-sublabel-line-height: 19px;\n--wpforms-button-size-font-size: 20px;\n--wpforms-button-size-height: 48px;\n--wpforms-button-size-padding-h: 20px;\n--wpforms-button-size-margin-top: 15px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-12834-custom-css\">\n\t\t\t\t#wpforms-12834 {\n\t\t\t\t\t.wpforms-form .wpforms-field-divider:first-of-type h3 { margin-top: 0!important; }\r\n.wpforms-form .wpforms-field-divider h3 { padding-top:0; }\r\n.wpforms-form .wpforms-field-divider { border-top-width: 1px; }\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-12834\"><form id=\"wpforms-form-12834\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"12834\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/nl\/wp-json\/wp\/v2\/codman\/11193\" data-token=\"d63855a295057753f567ebd8897f1a57\" data-token-time=\"1788349671\"><noscript class=\"wpforms-error-noscript\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/div><div class=\"wpforms-field-container\">\t\t<div id=\"wpforms-12834-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-12834-field_1\" >formulier? u naam<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-12834-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-12834-field_32-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-type=\"divider\" data-field-id=\"32\"><h3 id=\"wpforms-12834-field_32\" aria-errormessage=\"wpforms-12834-field_32-error\">Uw gegevens<\/h3><\/div><div id=\"wpforms-12834-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-12834-field_11\">Uw naam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12834-field_11\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-12834-field_11-error\" required><\/div><div id=\"wpforms-12834-field_12-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-12834-field_12\">Uw e-mailadres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12834-field_12\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][12]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12834-field_12-error\" required><\/div><div id=\"wpforms-12834-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-12834-field_33\">Wat is de naam van de samenwerking? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12834-field_33\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-12834-field_33-error\" required><\/div><div id=\"wpforms-12834-field_34-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"34\"><h3 id=\"wpforms-12834-field_34\" aria-errormessage=\"wpforms-12834-field_34-error\" aria-describedby=\"wpforms-12834-field_34-description\">Connect aanvragen voor<\/h3><div id=\"wpforms-12834-field_34-description\" class=\"wpforms-field-description\">Kies voor welk dashboard u Codman Connect wilt aanvragen. U kunt beide selecteren.<\/div><\/div><div id=\"wpforms-12834-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Dashboard <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-12834-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-12834-field_35_1\" name=\"wpforms[fields][35][]\" value=\"Codman Indicatoren\" aria-errormessage=\"wpforms-12834-field_35_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_35_1\">Codman Indicatoren<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-12834-field_35_2\" name=\"wpforms[fields][35][]\" value=\"Codman Exploratief\" aria-errormessage=\"wpforms-12834-field_35_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_35_2\">Codman Exploratief<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12834-field_46-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"divider\" data-field-id=\"46\" style=\"display:none;\"><h3 id=\"wpforms-12834-field_46\" aria-errormessage=\"wpforms-12834-field_46-error\">Codman Indicatoren<\/h3><\/div><div id=\"wpforms-12834-field_43-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-modern\" data-field-type=\"select\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-12834-field_43\">Codman Indicatoren registratie(s)<\/label><select id=\"wpforms-12834-field_43\" class=\"wpforms-field-large choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-large\" data-search-enabled=\"1\" name=\"wpforms[fields][43][]\" multiple=\"multiple\"><option value=\"\" class=\"placeholder\" disabled >Selecteer een registratie(s)<\/option><option value=\"AMSM (Antimicrobial stewardship)\"  class=\"choice-4 depth-1\"  >AMSM (Antimicrobial stewardship)<\/option><option value=\"DACI (halsslagader interventies)\"  class=\"choice-5 depth-1\"  >DACI (halsslagader interventies)<\/option><option value=\"DASA (beroertezorg)\"  class=\"choice-6 depth-1\"  >DASA (beroertezorg)<\/option><option value=\"DATO (obesitas)\"  class=\"choice-7 depth-1\"  >DATO (obesitas)<\/option><option value=\"DBIR (borstimplantaten)\"  class=\"choice-8 depth-1\"  >DBIR (borstimplantaten)<\/option><option value=\"DCRA (darmkanker)\"  class=\"choice-9 depth-1\"  >DCRA (darmkanker)<\/option><option value=\"DGEA (kijkonderzoek maag\/darm\/lever)\"  class=\"choice-10 depth-1\"  >DGEA (kijkonderzoek maag\/darm\/lever)<\/option><option value=\"DGOA (gynaecologische oncologie)\"  class=\"choice-11 depth-1\"  >DGOA (gynaecologische oncologie)<\/option><option value=\"DHBA (lever- en galwegen)\"  class=\"choice-12 depth-1\"  >DHBA (lever- en galwegen)<\/option><option value=\"DHFA (heupfractuur)\"  class=\"choice-13 depth-1\"  >DHFA (heupfractuur)<\/option><option value=\"DHNA (hoofd-hals oncologie)\"  class=\"choice-14 depth-1\"  >DHNA (hoofd-hals oncologie)<\/option><option value=\"DLCA-L\"  class=\"choice-15 depth-1\"  >DLCA-L<\/option><option value=\"DLCA-R\"  class=\"choice-16 depth-1\"  >DLCA-R<\/option><option value=\"DLCA-S\"  class=\"choice-17 depth-1\"  >DLCA-S<\/option><option value=\"DMTR (melanoom)\"  class=\"choice-18 depth-1\"  >DMTR (melanoom)<\/option><option value=\"DPARD (diabetes)\"  class=\"choice-19 depth-1\"  >DPARD (diabetes)<\/option><option value=\"DPCA (alvleesklierkanker)\"  class=\"choice-20 depth-1\"  >DPCA (alvleesklierkanker)<\/option><option value=\"DRAIM (Acute interne geneeskunde)\"  class=\"choice-21 depth-1\"  >DRAIM (Acute interne geneeskunde)<\/option><option value=\"DRCE (complicaties kijkonderzoek)\"  class=\"choice-22 depth-1\"  >DRCE (complicaties kijkonderzoek)<\/option><option value=\"DSAA (aorta interventies)\"  class=\"choice-23 depth-1\"  >DSAA (aorta interventies)<\/option><option value=\"DUCA (maag- en slokdarmkanker)\"  class=\"choice-24 depth-1\"  >DUCA (maag- en slokdarmkanker)<\/option><option value=\"EPSA (kinderchirurgie)\"  class=\"choice-25 depth-1\"  >EPSA (kinderchirurgie)<\/option><option value=\"NBCA (borstkanker)\"  class=\"choice-26 depth-1\"  >NBCA (borstkanker)<\/option><option value=\"NBCA-R\"  class=\"choice-27 depth-1\"  >NBCA-R<\/option><option value=\"PICE (Pediatrische Intensive Care)\"  class=\"choice-28 depth-1\"  >PICE (Pediatrische Intensive Care)<\/option><\/select><\/div><div id=\"wpforms-12834-field_44-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"44\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Welke indicatoren wilt u delen?<\/legend><ul id=\"wpforms-12834-field_44\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-12834-field_44_4\" name=\"wpforms[fields][44][]\" value=\"Verplicht transparante indicatoren\" aria-errormessage=\"wpforms-12834-field_44_4-error\" aria-describedby=\"wpforms-12834-field_44-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_44_4\">Verplicht transparante indicatoren<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-12834-field_44_5\" name=\"wpforms[fields][44][]\" value=\"Vrijwillig transparante indicatoren\" aria-errormessage=\"wpforms-12834-field_44_5-error\" aria-describedby=\"wpforms-12834-field_44-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_44_5\">Vrijwillig transparante indicatoren<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-12834-field_44_6\" name=\"wpforms[fields][44][]\" value=\"Interne indicatoren\" aria-errormessage=\"wpforms-12834-field_44_6-error\" aria-describedby=\"wpforms-12834-field_44-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_44_6\">Interne indicatoren<\/label><\/li><\/ul><div id=\"wpforms-12834-field_44-description\" class=\"wpforms-field-description\">(deze keuze geldt voor alle eerder geselecteerde registraties)<\/div><\/fieldset><\/div><div id=\"wpforms-12834-field_47-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"divider\" data-field-id=\"47\" style=\"display:none;\"><h3 id=\"wpforms-12834-field_47\" aria-errormessage=\"wpforms-12834-field_47-error\">Codman Exploratief<\/h3><\/div><div id=\"wpforms-12834-field_48-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-modern\" data-field-type=\"select\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-12834-field_48\">Codman Exploratief registratie(s)<\/label><select id=\"wpforms-12834-field_48\" class=\"wpforms-field-large choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-large\" data-search-enabled=\"1\" name=\"wpforms[fields][48][]\" multiple=\"multiple\"><option value=\"\" class=\"placeholder\" disabled >Selecteer een registratie(s)<\/option><option value=\"AMSM (Antimicrobial stewardship)\"  class=\"choice-29 depth-1\"  >AMSM (Antimicrobial stewardship)<\/option><option value=\"DACI (halsslagader interventies)\"  class=\"choice-30 depth-1\"  >DACI (halsslagader interventies)<\/option><option value=\"DASA (beroertezorg)\"  class=\"choice-31 depth-1\"  >DASA (beroertezorg)<\/option><option value=\"DATO (obesitas)\"  class=\"choice-32 depth-1\"  >DATO (obesitas)<\/option><option value=\"DBIR (borstimplantaten)\"  class=\"choice-33 depth-1\"  >DBIR (borstimplantaten)<\/option><option value=\"DCRA (darmkanker)\"  class=\"choice-34 depth-1\"  >DCRA (darmkanker)<\/option><option value=\"DGEA (kijkonderzoek maag\/darm\/lever)\"  class=\"choice-35 depth-1\"  >DGEA (kijkonderzoek maag\/darm\/lever)<\/option><option value=\"DGOA (gynaecologische oncologie)\"  class=\"choice-36 depth-1\"  >DGOA (gynaecologische oncologie)<\/option><option value=\"DHBA (lever- en galwegen)\"  class=\"choice-37 depth-1\"  >DHBA (lever- en galwegen)<\/option><option value=\"DHFA (heupfractuur)\"  class=\"choice-38 depth-1\"  >DHFA (heupfractuur)<\/option><option value=\"DHNA (hoofd-hals oncologie)\"  class=\"choice-39 depth-1\"  >DHNA (hoofd-hals oncologie)<\/option><option value=\"DLCA-L\"  class=\"choice-40 depth-1\"  >DLCA-L<\/option><option value=\"DLCA-R\"  class=\"choice-41 depth-1\"  >DLCA-R<\/option><option value=\"DLCA-S\"  class=\"choice-42 depth-1\"  >DLCA-S<\/option><option value=\"DMA (geneesmiddelen)\"  class=\"choice-43 depth-1\"  >DMA (geneesmiddelen)<\/option><option value=\"DMTR (melanoom)\"  class=\"choice-44 depth-1\"  >DMTR (melanoom)<\/option><option value=\"DNMA (neuromodulatie)\"  class=\"choice-45 depth-1\"  >DNMA (neuromodulatie)<\/option><option value=\"DPARD (diabetes)\"  class=\"choice-46 depth-1\"  >DPARD (diabetes)<\/option><option value=\"DPCA (alvleesklierkanker)\"  class=\"choice-47 depth-1\"  >DPCA (alvleesklierkanker)<\/option><option value=\"DPPA (pijn en palliatieve zorg)\"  class=\"choice-48 depth-1\"  >DPPA (pijn en palliatieve zorg)<\/option><option value=\"DRAIM (Acute interne geneeskunde)\"  class=\"choice-49 depth-1\"  >DRAIM (Acute interne geneeskunde)<\/option><option value=\"DRCE (complicaties kijkonderzoek)\"  class=\"choice-50 depth-1\"  >DRCE (complicaties kijkonderzoek)<\/option><option value=\"DSAA (aorta interventies)\"  class=\"choice-51 depth-1\"  >DSAA (aorta interventies)<\/option><option value=\"DUCA (maag- en slokdarmkanker)\"  class=\"choice-52 depth-1\"  >DUCA (maag- en slokdarmkanker)<\/option><option value=\"EPSA (kinderchirurgie)\"  class=\"choice-53 depth-1\"  >EPSA (kinderchirurgie)<\/option><option value=\"NBCA (borstkanker)\"  class=\"choice-54 depth-1\"  >NBCA (borstkanker)<\/option><option value=\"NBCA-R\"  class=\"choice-55 depth-1\"  >NBCA-R<\/option><option value=\"PICE (Pediatrische Intensive Care)\"  class=\"choice-56 depth-1\"  >PICE (Pediatrische Intensive Care)<\/option><\/select><div id=\"wpforms-12834-field_48-description\" class=\"wpforms-field-description\">Wanneer u Connect voor Exploratief aanvraagt worden alle uitkomsten uit Codman Exploratief gedeeld. Dit omvat zowel de transparante als niet-transparante data. Daarnaast zijn alle filters (m.u.v. behandelaarsfilters) beschikbaar voor zowel de eigen als gedeelde data. Wanneer er 10 pati\u00ebnten of minder overblijven voor een samenwerkende zorginstelling wordt de uitkomst niet getoond.\n\n<\/div><\/div><div id=\"wpforms-12834-field_36-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"36\"><h3 id=\"wpforms-12834-field_36\" aria-errormessage=\"wpforms-12834-field_36-error\" aria-describedby=\"wpforms-12834-field_36-description\">Tijdsperiode<\/h3><div id=\"wpforms-12834-field_36-description\" class=\"wpforms-field-description\">Hoe lang wilt u Codman Connect blijven gebruiken? Na afloop van deze periode wordt de functionaliteit automatisch stopgezet. Uw reguliere Codman dashboards blijven uiteraard actief. Indien u niets invult wordt er uitgegaan van 3 maanden. Codman Connect wordt binnen 2 weken na ontvangst van alle getekende DocuSign contracten geactiveerd.<\/div><\/div><div id=\"wpforms-12834-field_37-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">Voor welke periode wilt u Codman Connect gebruiken?<\/legend><ul id=\"wpforms-12834-field_37\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-12834-field_37_1\" name=\"wpforms[fields][37]\" value=\"Onbepaalde tijd\" aria-errormessage=\"wpforms-12834-field_37_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_37_1\">Onbepaalde tijd<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-12834-field_37_2\" name=\"wpforms[fields][37]\" value=\"12 maanden\" aria-errormessage=\"wpforms-12834-field_37_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_37_2\">12 maanden<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-12834-field_37_3\" name=\"wpforms[fields][37]\" value=\"3 maanden\" aria-errormessage=\"wpforms-12834-field_37_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_37_3\">3 maanden<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-12834-field_37_4\" name=\"wpforms[fields][37]\" value=\"1 maand\" aria-errormessage=\"wpforms-12834-field_37_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_37_4\">1 maand<\/label><\/li><li class=\"choice-6 depth-1 wpforms-other-choice\"><input type=\"radio\" id=\"wpforms-12834-field_37_6\" data-other-choice=\"true\" name=\"wpforms[fields][37]\" value=\"Anders\" aria-errormessage=\"wpforms-12834-field_37_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12834-field_37_6\">Anders<\/label><\/li><\/ul><input type=\"text\" id=\"wpforms-12834-field_37_other\" class=\"wpforms-other-input wpforms-field-required wpforms-field-large wpforms-hidden\" name=\"wpforms[fields][37][other]\" disabled=\"disabled\" required><\/fieldset><\/div><div id=\"wpforms-12834-field_38-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"38\"><h3 id=\"wpforms-12834-field_38\" aria-errormessage=\"wpforms-12834-field_38-error\" aria-describedby=\"wpforms-12834-field_38-description\">Deelnemende instellingen<\/h3><div id=\"wpforms-12834-field_38-description\" class=\"wpforms-field-description\"><p style=\"font-size:16px;\">Voor welke zorginstellingen wenst u Codman Connect te activeren? Alle zorginstellingen krijgen identieke functionaliteit overeenkomstig met de wensen uit dit formulier.<br \/><br \/>\n\n<strong>Benodigde informatie:<\/strong><\/p>\n<ol>\n<li style=\"font-size:16px;\">Namen van de zorginstellingen die deelnemen in Codman Connect samenwerking (inclusief uw eigen instellingen)<\/li>\n<li style=\"font-size:16px;\">Namen en emailadressen van de contactpersonen die binnen de zorginstellingen zorgen dat het Codman Connect contract ondertekend wordt door een geautoriseerd persoon<\/li>\n<\/ol>\nLet op: alle zorginstellingen met wie u data wilt delen dienen hieronder expliciet vermeld te worden inclusief contactpersoon. Zonder deze informatie kan de aanvraag niet worden verwerkt.<\/div><\/div><div id=\"wpforms-12834-field_39-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-12834-field_39\">Deelnemende instellingen <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-12834-field_39\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-12834-field_39-error\" aria-describedby=\"wpforms-12834-field_39-description\" required><\/textarea><div id=\"wpforms-12834-field_39-description\" class=\"wpforms-field-description\">Voorbeeld: DICA ziekenhuis, Frank de Jong, fdejong@dica.nl; Medisch Centrum MRDM, Ronald Jansen, rjansen@mrdm.nl<\/div><\/div><div id=\"wpforms-12834-field_40-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-12834-field_40\">Zijn er instellingen die afwijken van de ingevulde functionaliteiten in dit formulier?<\/label><textarea id=\"wpforms-12834-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-12834-field_40-error\" aria-describedby=\"wpforms-12834-field_40-description\" ><\/textarea><div id=\"wpforms-12834-field_40-description\" class=\"wpforms-field-description\">Hierbij kunt u denken aan een instelling die niet wilt deelnemen aan een bepaalde registratie of voor een kortere tijdsperiode\n\n<\/div><\/div><div id=\"wpforms-12834-field_41-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"41\"><div id=\"wpforms-12834-field_41-description\" class=\"wpforms-field-description\"><ul>\n<li style=\"font-size:16px;\">Door het invullen van dit formulier geeft u toestemming voor het gebruik van deze gegevens door MRDM<span class=\"conditional set-has-dica\"> en DICA<\/span>.<\/li>\n<li style=\"font-size:16px;\">De doeleinde voor het gebruik van deze gegevens beperken zich tot communicatie rondom de deelname aan de registratie(s) waarvoor er een samenwerkingsverband is tussen uw organisatie en MRDM en DICA.<\/li> \n<li style=\"font-size:16px;\">De via dit document bekende personen kunnen te allen tijde een verzoek indienen bij de Servicedesk voor rectificatie, verwijdering en opvraag van de bij ons bekende gegevens.<\/li>\n<li style=\"font-size:16px;\">De gegevens worden niet verder verspreid naar derden en worden opgeslagen bij MRDM voor zover er een samenwerkingsverband bestaat tussen uw organisatie en MRDM en DICA.<\/li>\n<li style=\"font-size:16px;\">MRDM is ISO 27001:2013 en NEN 7510:2011 gecertificeerd en waarborgt daarmee de veilige verwerking van persoonsgegevens.<\/li>\n<\/ul>\n<br \/><br \/><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-12834-field_1-container { position: absolute !important; 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