Axxess Technology Solutions, Inc. - Agreement Management System

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Internal Copy

NPI #

Contact:

Address:

Phone:

Email:

Fax:

Hi

Thank you for choosing Axxess, the leading home healthcare technology solutions provider. Below is a summary of what your Annual Agreement for commencing on will include.

Payment Authorization

Payment Method

Credit Card

Name on Card

Credit Card Number

Exp Date

Billing Address Billing Zip

**Beginning January 1, 2024, a 3% surcharge will be added to all credit card payments.

Bank Information

Bank Name *

Routing Number *

Account Number *

Upload VOIDED Check *

Accepted File Types: GIF, JPG, PNG, PDF
Max File Size: 2 MB

Additional Information

Tax ID Number *

Previous Software *

Medicare Provider Number

(if applicable)

Medicare Submitter ID

(if applicable)

State ID for OASIS Transmission

(if applicable)

Medicaid Number

(if applicable)

CAHPS Vendor

(if applicable)

Agency Census

Other Insurances Accepted

Referral Source

Training Coordinator Name

(primary contact for agency training)

Training Coordinator Email

Training Coordinator Phone

Go Live Date

I agree to the Terms and Conditions and that the above information is correct to the best of my knowledge. I hereby authorize Axxess Technology Solutions, Inc. to draft the amount from the account designated above as described. This payment is for the monthly service fees as agreed upon in Section 6 of the Axxess Service Level Agreement. I understand this agreement will stay in effect until terminated according to Section 15 of the Axxess Service Level Agreement. By submitting this form, I am electronically signing this document and confirm all of the information I have provided.

I agree that the above information is correct and I hereby authorize Note-e-fied Incorporated to use the credit card information provided to automatically draft the amount from the account for the agreed upon monthly service fees. I understand this authorization will remain in effect until terminated according to the terms of the original agreement. By entering my name and clicking submit, I am electronically signing this document, confirming agreement with all information provided herein.

please submit a copy of Tax-Exempt paperwork to accounting@axxess.com

Electronic Signature *
(Please enter your name)