ASP (Cloud) Termination Checklist Do note, STI requires at least 90 days' notice to cancel any service or invoicing. Also, there will a $250 fee to reactivate the STI Health Portal for e-prescribing and other services, and a $250 fee to reactivate Waystar for electronic billing, ERAs, and Eligibility.Please complete the following form when requesting termination of services from STI Cloud. Practice Name*Client ID / Account Number (can be found on Invoice):*Practice Address* Street Address City State / Province / Region ZIP / Postal Code Practice Tax ID*Contact Name* First Last Contact Phone*Contact Email* Date you will no longer need access to Waystar for sending claims.*Please take into consideration the amount of time needed to submit claims and work outstanding receivables. Do note, there is a $250 fee to reactivate this service. MM slash DD slash YYYY Date you will no longer need access to the STI Health Portal and Patient Portal.*Once deactivated you will no longer receive lab information or be able to electronically prescribe medications. In addition, your patients will no longer have access to the STI Patient Portal. Do note, there is a $250 fee to reactivate this service. MM slash DD slash YYYY Date you will no longer need access to additional ancillary services, such as Patient Reminder Module, Patient Pay Online, Mobile App, Electronic Patient statements, and eFaxing (Updox).* MM slash DD slash YYYY Date you no longer need access to your data in the ChartMaker Medical Suite (both financial and clinical) in the STI Cloud.*Data will be kept for 90 days beyond this date and then destroyed. (See data option plans below.) MM slash DD slash YYYY If you are receiving labs in Clinical, or have an interface where data is shared, did you contact the vendor to deactivate? Yes No Select the vendor(s) and the vendor termination date.* Health Information Exchange (HIE) Interface Hospital Interface Lab Bridge Interface (Practice Manager) Lab Results Interface (Clinical) Instrumentation/Equipment Interface Image Enabled Results Delivery (IERD) Accountable Care Organizations (ACO) Interface Physicians Organizations (PO) Interface Health Management Platform Health Information Exchange (HIE) Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hospital Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lab Bridge Interface (Practice Manager) Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lab Results Interface (Clinical) Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Instrumentation/Equipment Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Image Enabled Results Delivery (IERD) Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Accountable Care Organizations (ACO) Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physicians Organizations (PO) Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Health Management Platform Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you currently have a Managed Services contract?* Yes No Do you intend to keep your Managed Services contract with STI?* Yes No Managed Services Expiration Date*If you are cancelling your contract, please note that we require 90 days' notice. If you have paid the year in full there is no refund. MM slash DD slash YYYY Do you currently have an Offsite Storage contract?* Yes No Do you intend to keep your Offsite Storage contract with STI?* Yes No Offsite Storage Expiration Date*If you are cancelling your contract, please note that we require 90 days' notice. If you have paid the year in full there is no refund. You do have options to have the data saved to an external drive. Please contact Technical Sales for more information. MM slash DD slash YYYY Do you currently have an Office 365 contract?* Yes No Do you intend to keep your Office 365 contract with STI?* Yes No Office 365 Expiration Date*If you are cancelling your contract, please note that we require 90 days' notice. If part of your contract includes email exchange you will not be able to access the email after cancellation. If you have paid the year in full there is no refund. MM slash DD slash YYYY Do you currently have a Domain contract?* Yes No Do you intend to keep your Domain contract with STI?* Yes No Domain Expiration Date*If you are cancelling your contract, please note that we require 90 days' notice. If you have paid the year in full there is no refund. If you cancel with STI your Domain (@abc.com) will no longer be live, so any website or email domain will no longer work. MM slash DD slash YYYY Do you currently have a separate Virus/Spam/Malware/Encryption contract?* Yes No Do you intend to keep your Virus/Spam/Malware/Encryption contract with STI?* Yes No Virus/Spam/Malware/Encryption Expiration Date*If you are cancelling your contract, please note that we require 90 days' notice. If you have paid the year in full there is no refund. If you cancel your contract, you should have another license ready to install. Your most important priority is to keep your network secure. MM slash DD slash YYYY Method to reach you once office is changed or closed* Phone Email What do you plan to do with your data in the STI Cloud?*Please choose one of the following five options. The ChartMaker Medical Suite allows you to print and export data yourself. If you currently own a license for The ChartMaker Medical Suite we may be able to install the product and your data on your equipment. STI can host your Data in the STI Cloud in Read-Only Mode for a monthly fee. STI can convert all of your financial and clinical data to PDF files for an additional fee. None of the above. Reason for Termination*Additional CommentsPlease check to acknowledge:* By checking this checkbox, I acknowledge that STI is not Responsible to keep ChartMaker data backups of our Clinical and Financial data beyond 90 days once we cancel STI off-site backup services or STI ASP/Cloud services. Authorized SignatureDate MM slash DD slash YYYY
