Healthcare Clientele

Practice Information
Practice Name: *
Parent Company Name: *
Address: *
(no PO Box)
Office Phone: *
Fax: *
Back Office Phone: *
Website: *
Medical Specialties: *
Practice Contacts
Practice Manager: *
Email: *
Phone: *

Contact Name:
Email:
Phone:
Billing Contacts
Billing Contact Name: *
Are you sure this is the Billing contact? *
Billing Email: *
Phone: *
Receive invoices by: *

Other Billing Information:
Scheduling & Hours
Daily Summary Delivered Via: *

At what times? *
Select at least one time slot
Does an on-call schedule exist?
Do you plan to use Anserve during lunch hours?

Lunch Start:

Lunch End:

Office Hours:
Choose when your office is OPEN
From: To:
From: To:
From: To:
From: To:
From: To:
From: To:
From: To:
Other
Call Relay Instructions:
Hospital Affiliation(s):
Are you Available for Non PTS After-Hours?
[simple_tooltip content="Some description for the Non PTS field here"]What’s this?[/simple_tooltip]

Menu