For your office, please fill out the following:

1. Office name:  

2. Address:  

3. Phone:  

4. Fax:       

5. Email:    

6. NPI:       

7. EIN:       

8. Logo (send as attachment)

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

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

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

12. 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.  

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

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

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

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

For providers:
1. Full name along with credentials:  

2. Email (must be different than the office email):  

3. NPI:  

For administrators and non-clinical staff:
1. Full name along with credentials:  

2. Email (must be different than the office email):  

Billing enrollment:
1. Individual or facility name with address (include the 9 digit zip code) of the credentialed entity  

2. Individual or facility NPI of the credentialed entity  

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

4. SSN or TaxID of the credentialed entity  

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

Leave this empty:

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Document name: HelloNote Onboarding

Unique Document ID: 32a6fd46ee024b23d6d3e55e8fc2003b5764db62

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Timestamp	Audit
October 22, 2021 4:04 pm EDT	HelloNote Onboarding Uploaded by HelloNote EMR - hello@hellonote.com IP 100.2.23.184
November 10, 2021 11:43 am EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
November 11, 2021 3:18 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
November 11, 2021 3:27 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
November 11, 2021 3:28 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
December 1, 2021 10:54 am EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
December 1, 2021 10:55 am EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
December 1, 2021 10:56 am EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 11, 2022 1:23 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 11, 2022 1:25 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 11, 2022 1:27 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 11, 2022 1:29 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 11, 2022 1:30 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 15, 2022 4:46 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 15, 2022 4:53 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 15, 2022 4:54 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 15, 2022 4:54 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 15, 2022 4:59 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 16, 2022 5:46 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 16, 2022 5:53 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147
February 16, 2022 5:54 pm EDT	Donna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147

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https://hellonote.com/

Audit Trail Serial# 855be570cb0430b4d69da3dde5aec957