Client Server 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 Provider Complete through Change Healthcare for electronic billing and ERAs. Please complete the following form when requesting termination of services for a client server.Practice Name*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 Provider Complete 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. Date Format: 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. Date Format: 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).* Date Format: MM slash DD slash YYYY Do you currently have a Managed Services contract?*YesNoDo you intend to keep your Managed Services contract with STI?*YesNoManaged 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. Date Format: MM slash DD slash YYYY Do you currently have an Offsite Storage contract?*YesNoDo you intend to keep your Offsite Storage contract with STI?*YesNoOffsite 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. Date Format: MM slash DD slash YYYY Do you currently have an Office 365 contract?*YesNoDo you intend to keep your Office 365 contract with STI?*YesNoOffice 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. Date Format: MM slash DD slash YYYY Do you currently have a Domain contract?*YesNoDo you intend to keep your Domain contract with STI?*YesNoDomain 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. Date Format: MM slash DD slash YYYY Do you currently have a separate Virus/Spam/Malware/Encryption contract?*YesNoDo you intend to keep your Virus/Spam/Malware/Encryption contract with STI?*YesNoVirus/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. Date Format: 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 ChartMaker Medical Suite?*Please choose one of the following four options.Continue to Pay Basic Software Support and Hardware Support. We can provide you with costs for basic support.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 CommentsAuthorized SignatureDate Date Format: MM slash DD slash YYYY
