Vital Touch Sales

Contact

Client Details (Not quite ready for contracts)

READY FOR CONTRACTS

Please complete the following form with as much detail as possible. This information will be used to create the necessary agreements and facilitate the onboarding and enrollment of patients into Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) Services.

Sales Rep Name, Email, Phone:

If there is a Secondary Sales Rep:

What is the name of the Medical Practice? (not the Doctor's name).

This is the Practice name that will be used for the agreements:

What is the Physician Name?

Please use the following format:
Dr. [first name] [last name] (for example, Dr. John Smith)

What is the main email address?

Please enter the email address that the Contracts, Agreements, and Notifications need to be sent.

What is the main office phone number?

What is the main office address? This address will go on the contracts.

Please share the contact details (name, email address, and phone number) of the designated person in the practice with whom our clinicians should communicate regarding patient requests and issues.

Office Manager contact information.
We find that many medical practices have an Office Manager to coordinate activities between Vital Touch and the practice. Please provide that person's contact information below:

Office Manager Name
Office Manager Email Address
Office Manager Phone

What type of practice is this?

(Cardiology, Internal Medicine, Family Practice, Home Health etc.)

Please state the number of Providers (Dr's., PA's, NP's, etc.) in the practice who will be referring patients to RPM and CCM services.

Which patient engagement programs is the Practice interested in? Check all that apply.

Remote Physiological Monitoring (RPM)

Chronic Care Management (CCM)

Appointment Reminders

Patient Communication & Support (Lab Results, Prescription Refills)

Pre-Appointment Reports

Please estimate the total number of SERVICES-ELIGIBLE patients the practice currently has in all locations. (Generally this be the number of Medicare Patients)

Please specify the brand and version number of the EHR software:

EHR Contact:

EHR Admin Name
EHR Admin Email Address
EHR Admin Phone Number

Who is the Practice going to use for Billing?

(Default is Nobility)

Gateway Medical Solutions (PREFERRED)

Nobility (if over $50k billing volume)

Athena (Practice must already by with Athena)

Doctor will do own Billing (Need to complete certification $1,500)

What is the NPI of the entity who the practice will be billing under?

Please enter the name and contact information for the person in your office that we can contact regarding Billing:

Billing Contact Person
Email Address
Phone Number

Sales Rep Notes (if any):

Once you click Submit below, the Contracts will be prepared and sent for digital signature within 24-48 hours. Please tell the Doctor to look for an email from vitaltouchvps.com

Once Contracts are signed and completed we will send an email to schedule a Launch Call where they will meet the team and begin Onboarding to our services.