Patient Reminder Module – Enrollment Form Patient Reminder Module – Enrollment Form The ChartMaker® Medical Suite Patient Reminder Module monthly fee is based on reminder volume. The estimated monthly fee for the Patient Reminder Module is based upon information provided by the client. A reminder is based on the telephone number or email address provided and is only calculated when a successful connection to a patient or a patient’s answering machine is detected and/or if an email was delivered (and did not come back as undeliverable). Any significant changes to this monthly volume will cause the monthly fee to change to the rate that is shown below. One time setup fee for Reminders and Recalls is $250. Once one service is activated, the other must be activated within a 30 day period. Additional setup after the initial 30 day period will be invoiced at $150. The Broadcast Setup Fee (Optional) is $75.00. The ChartMaker® Medical Suite Patient Reminder Module monthly rates: 1 – 1,000 Reminders per month: $0.19 each 1,001 – 2,500 Reminders per month: $0.17 each 2,501 – 5,000 Reminders per month: $0.15 each Special Promotion: To assist clients during the COVID-19 pandemic, we are offering a Special Promotion to help send messages to your patients: Free Broadcast Service Setup! For the duration of the COVID-19 public health emergency, the $75 setup fee will be waived for all clients needing to reach out to their patients using the Patient Reminder Module's Broadcast Service. This promotion is available for both new and existing clients. When enrolling, check the Broadcast Service option to sign up. In the form below, the Practice Name, Contact information, and Email address to open an account with are all that is required for clients seeking the Broadcast Service only. Note: To install the Patient Reminder Module, your office MUST be on CMMS version 6.4.6 or higher. Practice Name** Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Contact Name* First Last Contact Phone*Check the service(s) you wish to sign up for:* Appointment Reminder Service Recall Reminder Service Broadcast Service (Setup Fee is Waived during COVID-19 Public Health Emergency) Select from the following options:1 – 1,000 Reminders per month1,001 – 2,500 Reminders per month2,501 – 5,000 Reminders per monthEnter the Total Amount of Estimated Appointment and/or Recall Reminders per month:Estimated Cost for Reminders per month: $0.00 Check the box below to acknowledge the following statement:*I acknowledge the following: There is a one time setup fee for the Reminder and Recall service of $250. Once one service is activated, the other must be activated within a 30 day period. Additional setup after the initial 30 day period will be invoiced at $150. If the Broadcast service is selected, there is an additional setup fee of $75.00 (waived during COVID-19 Public Health Emergency). I am aware and give consent for the setup fee(s) and estimates above Setup InformationMain Phone Number(s) of the practice that will display on the patient’s Caller ID:For the Appointment Reminder Service, enter how many days (1-5 days) BEFORE the appointment that you would like to send a reminder: *Note: it is not cost-effective to send two types of reminders on the same day:EMAIL REMINDEREnter a number between 1-5 daysCALL REMINDEREnter a number between 1-5 daysTEXT REMINDEREnter a number between 1-5 daysDo you want the patient to be prompted to Confirm or Reschedule the appointment? (If not, a message will tell them to call the office to reschedule)YesNoIf yes, do you want an email sent out immediately when a patient requests to reschedule?YesNoEnter email address that will be notified: Call/Text reminders start at (top of the hour): : HH MM AM PM Select on which days to NOT send reminders, starting at the time shown directly above: (not on major holidays automatically) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Call/text no later than (top of the hour): : HH MM AM PM Retry every (#) of hours:Maximum attempts per day:Number of office Locations:Number of Providers:Email address to open an account with (email addresses will be used as usernames):* If you do not currently have an STI Technical Services/Hardware contract, please provide us with the contact name and phone number of your IT Provider. Name First Last Phone
