Medical and Commercial Answering Services - Signup Today

Please select the service type you wish to sign up for

	Medical Services

Date To Begin Service:
Answer Phrase:
Business Name:
FEI or SS:
Address:
City, State, Zip:

Billing Address (if different from above):
City, State, Zip:

Web Site Address:
Office Telephone Numbers:
Office # Office #
Private # Fax #
Alt # Alt #

Office Hours:
	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
OPEN:
LUNCH:
LUNCH:
CLOSE:

Office Manager #

Email Address

Contact #

How Do You Wish to Receive Your Non-Urgent Messages?

Fax VoiceMail Email *

*Email requires that it is sent to a password protected address.

If Email Which Address?

If We Will Be Managing Your Oncall Schedules; Who Will Be Our Point Of Contact?
Name: Phone: Email:
How Did You Hear About Our Company?

Comments:

ASSOCIATE CONFIDENTIAL INFORMATION

Full Name: Specialty:

Phonetic Spelling (If necessary):

Cell#:		Home#:		Alt#:
Pager#:	Digital / Alphanumeric

Which Company Supplies Air Time?

Cell: Pager:

Our policy is never to give out any of your personal contact numbers. Is there a situation where this does not apply that you would like us to notate for your account?

Our policy is to verify that a return call has been made back on any Dr to Dr, Emergency Room, STAT, OB,

and Bleeding patient or patients with life-threatening symptoms messages. Would you like us to do this for your account?

Yes No

Comments:

Do you accept calls directly from hospitalized patients?

Yes No

May We Give Out The Home/cell number To Hospitals After 10 PM?

Yes No

Do You Accept Calls After Hours Regarding Refills?

Yes No

Do You Accept Calls After Hours Regarding New Patients?

Yes No

Between 7AM & Your Office Opening , How Would You Like To Receive Urgent Calls?

During Office Hours, How Would You Like To Receive Urgent Calls?

Between Office Closing & 10PM, How Would You Like To Receive Urgent Calls?

Between The Hours Of 10PM & 7AM, How Would You Like To Receive Calls?

*Note: Alpha Page/Text Message is the MOST cost effective type of dispatching. Dialing a digital pager, cellular phone or home number will incur additional operator units.

**Note:Please be sure if using a cellular device to receive messages, it is password protected. If there is any message information you would like us to omit from the transmissions, please notate

“ROUTINE Calls” (i.e. consults, newborns, expirations, patient transfers) Are held between 10PM & 7AM and then sent to your preferred method of dispatch, unless otherwise stated

Oncall coverage begins when your office closes and ends when your office reopens, unless otherwise stated

List All Hospitals or Facilities You Do Rounds At, or Are Affiliated With:

List all physicians you share oncall rotation with (please include their office # if they are not on our service)

"Comments

I agree that this signature will be the electronic representation of my signature.
Full Name

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	Commercial Services

Date To Begin Service:
Answer Phrase:
Business Name:
FEI or SS:
Address:
City, State, Zip:

Billing Address (if different from above):
City, State, Zip:

Web Site Address:
Office Telephone Numbers:
Office # Office #

Office Hours:
	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
OPEN:
LUNCH:
LUNCH:
CLOSE:

Office Manager #

Email Address

Contact #

How Do You Wish to Receive Your Non-Urgent Messages?

Fax

VoiceMail

Email *

Text

If Email Which Address?

Please list names,numbers and contact preferences for all other staff we may need to reach out to.
Name: Phone: Email:
How Did You Hear About Our Company?

Additional Instructions:

LQRC3F To prevent spam, enter the code shown above

Professional Answering Services

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BAY AREA MEDICAL EXCHANGE

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Medical or Business Answering Services

Medical Services

ASSOCIATE CONFIDENTIAL INFORMATION

Commercial Services