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 #
Private #
Alt #

Office Hours:
MonTuesWedThursFri Sat Sun
OPEN:
LUNCH:
LUNCH:
CLOSE:

Office Manager #Email Address
Contact #Contact #

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

*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#:DigitalAlphanumeric

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?

Comments:

Do you accept calls directly from hospitalized patients?
May We Give Out The Home/cell number To Hospitals After 10 PM?
Do You Accept Calls After Hours Regarding Refills?
Do You Accept Calls After Hours Regarding New Patients?

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