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Office Information

Office Name

Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

NPI

EIN

Please upload your logo

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Is this a facility/clinic or in-home office?

Facility/Clinic
In-Home

Go-live date (please give us a few date and time options to accommodate a training session):

Option 1

Date

Time

Option 2

Date

Time

Option 3

Date

Time

What would you like your default office calendar start and end time to be?

Do you have a review link we can add (Ex: Google)? This will allow you to send an SMS to a patient with a click of a button to review your practice

Would you like to enable auto-scheduling after each note is completed? If not, please ensure you are scheduling your visits.

When you log in to HelloNote, would you like it to take you to the dashboard by default, or the main screen?

Dashboard
Main Screen

Default Place of Service (Ex: Office/Clinic, Home/Mobile, Telehealth)

Do you want to automatically lock notes after a certain time period? Ex: 48 hours after the note is initiated?

For Providers

Full name along with credentials:

Provider's Individual Email

NPI

For administrators and non-clinical staff:

For Administrators & Non-clinical Staff

Full name along with credentials:

Primary Admin / Manager Email

Billing Enrollment

you and you

Individual or facility name

Address (include the 9 digit zip code) of the credentialed entity

Individual or facility NPI of the credentialed entity

Individual or facility PTAN (for Medicare) of the credentialed entity

What Primary Insurance PayerID(s) do you need us to include? Including Medicare and any other insurances. Please see the attached file. http://hellonote.com/forms

Submitter Information

Tell us who is completing this form today.

Your Name

First

Last

Your Email

Signature

Clear Signature

Specialization

By Role

Business Needs

Specialization

By Role

Business Needs

Kiosk

Scheduling

Documentation

Compliance & Billing

Telehealth

Analytics & Reporting

Patient Engagement

AI Powered Features

Kiosk

Scheduling

Documentation

Compliance & Billing

Telehealth

Analytics & Reporting

Patient Engagement

Ai Powered Features

Specialization

By Role

Business Needs

Specialization

By Role

Business Needs

Kiosk

Scheduling

Documentation

Compliance & Billing

Telehealth

Analytics & Reporting

Patient Engagement

AI Powered Features

Kiosk

Scheduling

Documentation

Compliance & Billing

Telehealth

Analytics & Reporting

Patient Engagement

Ai Powered Features

Specialization

By Role

Business Needs

Specialization

By Role

Business Needs

Kiosk

Scheduling

Documentation

Compliance & Billing

Telehealth

Analytics & Reporting

Patient Engagement

AI Powered Features

Kiosk

Scheduling

Documentation

Compliance & Billing

Telehealth

Analytics & Reporting

Patient Engagement

Ai Powered Features

Specialization

By Role

Business Needs

Specialization

By Role

Business Needs

Kiosk

Scheduling

Documentation

Compliance & Billing

Telehealth

Analytics & Reporting

Patient Engagement

AI Powered Features