Secure Form

Multi-Organization Request

This form should only be used for current customers adding to their existing order. If you are a new customer, please use this form: New Client Information Form

Customer Name: (This is the name of the paying entity for the services.)

Type of Company:

How many facilities with this order?

Are any of these facilities newly acquired by your company in the last 90 days?

Yes

Please list any Help Desk Instructions or other comments here.

Licensing and Billing

Mediprocity secure messaging services are licensed and billed on a per-user access code basis. Customer may reassign, deactivate, or disable user access codes internally; however, such actions do not automatically modify the quantity of licensed access codes or associated recurring fees month-to-month.

Any request to reduce licensed access code quantities must be submitted to Mediprocity in writing through authorized support channels. Billing adjustments, if approved, will apply prospectively beginning with the next billing period and will not be applied retroactively.

Your Information

Name of person filling out this form: *

Your email address:

Your company name: *

Are you a Mediprocity administrator for your organization? *

Yes

If not, please enter your organization’s admin name here:

Desired completion date for this request:

Please note that a 3 business day turnaround is expected for all requests. If your request is urgent, please follow up with our helpdesk at support@Mediprocity.com after you submit this form.

Signature:

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Use your finger or mouse to sign your signature in the box above.

Today's Date:

I accept the legal terms and conditions *

Mediprocity Inc.
12977 N 40 Dr
Suite 203
Creve Coeur, MO
63141-8655
mediprocity.com
support@mediprocity.com