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

Note: To install the Patient Reminder Module, your office MUST be on CMMS version 6.4.2 or higher.

Practice Name*

*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name*

First Last

Contact Phone*

Check the service(s) you wish to sign up for:*

Appointment Reminder Service
Recall Reminder Service
Broadcast Service (Extra $75.00 Setup Fee)

Select from the following options:

1 – 1,000 Reminders per month
1,001 – 2,500 Reminders per month
2,501 – 5,000 Reminders per month

Enter 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.

I am aware and give consent for the setup fee(s) and estimates above

Setup Information

Main 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 REMINDER

Enter a number between 1-5 days

CALL REMINDER

Enter a number between 1-5 days

TEXT REMINDER

Enter a number between 1-5 days

Do 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)*

Yes
No

If yes, do you want an email sent out immediately when a patient requests to reschedule?*

Yes
No

Enter email address that will be notified:*

Call/Text reminders start at (top of the hour):*

: HH

MM

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

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

Patient Reminder Module – Enrollment Form

Setup Information