Practice Billing Details

Please provide the following information. Fields marked with an are required.

1. Billing Company Information

Existing Client Holder Account # Legal Business Name * DBA / Trade Name (if different) Business Address * City * State * ZIP * Primary Contact Name * Title Phone * Mobile Email * Website

2. Billing Company Contacts

Administrative Contact

NameEmailPhone

Billing / Accounts Payable Contact

NameEmailPhone

Technical Contact

NameEmailPhone

5. Client Practices

Initial Number of Client Practices Estimated Number of Providers

6. Client / User Information

Use the button below to add and sign the information for a client or user. You will return here to complete the Billing Company authorization.

No Client/User information has been added.

Additional Notes or Details

Please email any additional forms to support@medi-ehr.com.

Payment Authorization *

I agree to Terms of Service

I am an authorized representative of the provider, practice and/or facility and agree to the Medi-EHR Provider SaaS & EHR Services Agreement and the Business Associate Agreement (BAA). I understand that this submission constitutes a binding order form and authorizes Medi-EHR to bill the payment method on file in accordance with those agreements.

Electronically signed by * Promo Code

Practice Billing Details

Selected Billing Plan

1. Billing Company Information

2. Billing Company Contacts

Administrative Contact

Billing / Accounts Payable Contact

Technical Contact

5. Client Practices

6. Client / User Information

Payment Authorization *

Contacts

Access

Certification(s)

Terms and conditions

Features

Mobile App(s)