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?

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