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.

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 Primary Provider's NPI 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:

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.

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 of the EHR software:

EHR Contact:

Who is the Practice going to use for Billing?

(Preferred is Gateway Medical Solutions)

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

Sales Rep Notes (if any):