New Client Information Form

Facility / Organization Information

(Helpful Hint: one facility that has it's own org normally requires a minium of 6 codes)

Payment Information

Payment / General Terms

Mediprocity takes credit cards and it is the preferred method of payment. A receipt will be emailed monthly.

Mediprocity can invoice customers who request as long as they their monthly total is higher than $100.00. Invoices are emailed and must be paid within 30 days. If an invoice runs past 60 days all accounts may be deactivated on Mediprocity until payment is received and reactivation fees may apply.

If the account continues to run late, due under this Agreement shall be subject to a service charge of one and one-half percent (1.5%) for each month or fraction thereof during which such amounts remain unpaid. Accounts that continue to pay late may be required to convert from Invoice to Credit Card status or have all accounts deactivated on Mediprocity.

  • Pricing is based on total number of users and may be adjusted to reflect material changes in capacity, or if you were given a discount.
  • Unless otherwise stated all training is done via webinar only and each company is allowed (1) admin training and (1) staff training at no cost.
  • All reasonable travel expenses and lodging expenses associated with training will be invoiced separately at $150 per hour.
  • Agreement and pricing have been determined for a month-to-month charge. There is no long term contract, but there is a 30-day notice to quit.
  • Prices are subject to change.

If you wish to pay by credit card - please log into your Mediprocity account and navigate to your Profile and then click on Subscription. Client agrees to sign Mediprocity Business Associate agreement prior to transmitting any Protected Health Information. Mediprocity can also sign your organization's BAA.

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714 Spirit 40 Park Drive - Suite 140
Chesterfield, MO 63005
(636) 812-0242