This is for requesting contracts. Fill out only when READY for CONTRACTS.
Request a Contract if your doctor is ready to sign.
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:
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.
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 select where your patients reside.
Please Enter EHR name below:
Please estimate the total number of SERVICES-ELIGIBLE patients the practice currently has in all locations. (Generally this be the number of Medicare Patients)
Who is the Practice going to use for Billing?
(Preferred is Gateway Medical Solutions)
Please enter Website below:
Sales Rep Notes (if any):
DOCUMENT DOWNLOADS
If a download link says "SAMPLE" then you will need to either customize it or ask Vital Touch to customize it before using
Patient Take-Home Flyer
This is an un-branded version of a Patient Take-Home flyer.
We want a version of this in every Doctor's office. The Doctor can personalize it to his/her practice.
Escalation Protocols
This document shows our Escalation Protocols for the most common scenarios.
Presentation
You can click to view an online presentation
Most Common ICD-10 Codes
This document shows the most common ICD-10 codes for RPM and CCM
The Form below is only for registering a NEW LEAD. This is not for requesting contracts.
Register New Lead in Sales Pipeline
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:
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.
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 select where your patients reside.
Sales Rep Notes (if any):
