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Healthcare Virtual Assistant New Plan

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Please complete the form below. All fields are required.

A representative will contact you once the form is recieved to get your Virtual Assistant services started!

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Your Information
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Business Information
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Business Address:

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Staff Details
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Target Region:

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Details and Requirements
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Daily Triage Contacts
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Reports To Contact
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Billing Contact
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Operating Details
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Days of Operation:

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Applications

Select the applications you need or will provide.

Applications Needed:

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Applications Providing:

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Electronic Medical Records

Select EMR requirements.

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Submit Application

Please review the Terms and Conditions and Business Associate Agreement. You will be agreeing to these terms when your service agreement is finalized.

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