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Healthcare Clientele

    Practice Information

    Practice Name: *

    Parent Company Name:

    Address: *
    (no PO Box)

    Office Phone: *

    Fax: *

    Back Office Phone: *

    Website: *

    Medical Specialties: *

    Cost Center #:

    Practice Contacts

    Practice Manager: *

    Email: *

    Phone: *

    [group group3]

    Contact Name:

    Email:

    Phone:

    [/group]

    Billing Contacts

    Billing Contact Name: *

    Are you sure this is the Billing contact? *

    Billing Email: *

    Phone: *

    Receive invoices by: *


    [group group12]

    [/group]
    [group group13]

    [/group]

    Other Billing Information:

    Scheduling & Hours

    Daily Summary Delivered Via: *


    [group group1]

    [/group]
    [group group2]

    [/group]

    At what times? *
    Select at least one time slot

    Does an on-call schedule exist?

    Do you plan to use Anserve during lunch hours?


    [group group4]

    Lunch Start:

    Lunch End:

    [/group]

    Office Hours: *
    Choose when your office is OPEN

    [group group5]
    From:To:
    [/group]

    [group group6]
    From:To:
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    [group group7]
    From:To:
    [/group]

    [group group8]
    From:To:
    [/group]

    [group group9]
    From:To:
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    From:To:
    [/group]

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    From:To:
    [/group]

    Other

    Call Relay Instructions:

    Hospital Affiliation(s):

    Are you available for non-patients after-hours?