HelloNote

HelloNote Onboarding


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):

 

 

 

 

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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Signature Certificate
Document name: HelloNote Onboarding
lock iconUnique Document ID: e581d5782248fdf09ad787872f4fdd56a06bb244
Timestamp Audit
October 22, 2021 4:04 pm ESTHelloNote Onboarding Uploaded by HelloNote EMR - hello@hellonote.com IP 108.6.11.147
November 10, 2021 11:43 am ESTDonna 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 ESTDonna 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 ESTDonna 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 ESTDonna 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 ESTDonna 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 ESTDonna 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 ESTDonna Dadivas - Donna@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 108.6.11.147