Anserphone - Medical Answering Application

AnsweringUSA.com

by Anserphone

Medical Answering Application

Physician Information
Name				Specialty
Street				Home Phone
City		State	Zip	2nd line
Beeper				Svc Provider
Cell				Svc Provider
Do you prefer to receive text messages via your beeper or cell?

Office Information
Street				Phone
City		State	Zip	Back line
Fax					(exchange use only)
Nurse				Office Mgr
Hours				Dr's Hours

Street				Phone
City		State	Zip	Back line
Fax					(exchange use only)
Nurse				Office Mgr
Hours				Dr's Hours

Street				Phone
City		State	Zip	Back line
Fax					(exchange use only)
Nurse				Office Mgr
Hours				Dr's Hours

Please list any partners and/or alternates
Name				Office #(s)
Home				Exchange
Other

Name				Office #(s)
Home				Exchange
Other

Name				Office #(s)
Home				Exchange
Other

Name				Office #(s)
Home				Exchange
Other

Name				Office #(s)
Home				Exchange
Other

Emergency Locates (Religious Organizations, Clubs, Friends, Relatives, etc...)


Hospitals


Clinics


Specific / Special Instructions
Please list any specific or special instructions. (Include any preferences for incoming messages and/or dispatching of calls or messages day, evening, and night. NOTE: Please be specific)


How did you hear about us?
	Referred by				Yellow Pages
	Advertisement				Internet
	Other

Bill To
Name
Street
City		State	Zip

Service Activation Date Requested

You will be automatically billed every 28 days. You will be responsible for any long distance and extra fees we incur from any outside agencies at your request. We are an after hours emergency service and are staffed based on after hours of operation information given by our clients. We reserve the right to charge for additional services requested and/or provided at your request. In addition, we reserve the right to adjust rates. We will provide written notice prior to price adjustments. In the event of cancellation of services, we MUST receive, in writing, a written notification 30 days prior to cancellation. You will be reminded of the cancellation procedure with each invoice. You will be subject to any fees incurred for collections efforts by an outside agency in addition to your outstanding balance due. It is the client's responsibility to provide up-to-date contact information and account information, as it changes and needs to be updated in our databases. We respect your privacy and do not share any private information with any outside sources.