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	SaaS Agreement Fields
	PAGE 1: View
	Effective Date:
	Client:
	Principal Place of Business:
	EIN:
	Initials:
	PAGE 2: View
Disclosure: By typing your name and clicking the "Submit" button, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. By clicking "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Document. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Company, or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You further agree that your signature (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Demo. You are also confirming that you are the individual authorized to enter into this Agreement.
	Sign By:
	Name:
	Its:
	Initials:
	PAGE 3: View
	Initials:
	PAGE 4: View
	Initials:
	PAGE 5: View
	Initials:
	PAGE 6: View
	Agreed and Accepted By:
Disclosure: By typing your name and clicking the "Submit" button, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. By clicking "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Document. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Company, or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You further agree that your signature (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Demo. You are also confirming that you are the individual authorized to enter into this Agreement.
	Signature and Title:
	PAGE 7: View
	Initials:
	PAGE 8: View
	Initials:
	PAGE 9: View
	Initials:
	PAGE 10: View
	Initials:
	PAGE 11: View
	Initials:
	PAGE 12: View
	Initials:
	PAGE 13: View
	Initials:
	PAGE 14: View
	Effective Date:
	Client:
	Principal Place of Business:
	EIN:
	PAGE 15: View
Disclosure: By typing your name and clicking the "Submit" button, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. By clicking "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Document. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Company, or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You further agree that your signature (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Demo. You are also confirming that you are the individual authorized to enter into this Agreement.
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	Patient Registration	Show▼

	First Name:
	Last Name:
	Address / Street:
	City:
	State:
	Zip:
	Phone:	() -
	Date of Birth:
	Gender:
	Email:
	Do you have Home Health?	Home Health Agency:
	Equipment Provider (required):
	ATP/Provider Representative (required):
	Primary Insurance:	Provider: Group #: Member ID:
	Secondary Insurance:	Provider: Group #: Member ID:

	Patient Acknowledgement & Medical Release To Obtain Medical Records
	I understand I have a choice of who provides my healthcare and have chosen practitioners (physicians and therapists) to perform my medical evaluation as required for prescribed equipment, supplies and services. I hereby authorize and request the release of my Personal Health Information (PHI) by Medical Practice in addition to any other of my medical care providers, emergency contact person/s, hospitals facilities or other third party institutions to for the purpose of medical services:
	Entire record:
	Entire record except:	Mental health records
		Communicable diseases (including HIV and AIDS)
		Alcohol / drug abuse treatment
		Other, please explain:
	I understand this consent is effective on the date I sign it. It may be revoked at any time by delivering written notice to and the revocation will be effective as of the date received, except to the extent has taken action in reliance of this consent. This consent is valid for one year from the effective date. Information disclosed pursuant to the authorization may be re-disclosed by the recipient and no longer protected by the federal privacy regulations I understand that I have the right to refuse to give this consent I acknowledge that I have received a copy of the Provider Notice of Privacy Practices as required by the Health Information Portability and Accountability Act (HIPAA). I understand that upon completion of reading the notice, any questions I may have may be addressed to the Provider. I acknowledge that I have received all Patient Handouts (Click here to download) including Patient Rights, and I understand that I have a choice of clinician to perform my evaluations. I acknowledge that I have chosen to perform my evaluation. I authorize the release of any medical or other information necessary to process my Health Insurance Claim. I also request payment of government benefits either to myself or to the party who accepts assignment on my Health Insurance Claim. I authorize payment of medical benefits to for services described on my Health Insurance Claim.
	Patient Consent to Telehealth
	I agree to be treated via a Telehealth Video and/or Audio Conference visit and acknowledge that I may be liable for any relevant co-pay or coinsurance depending on my insurance plan. I understand that this Telehealth Video and/or Audio Conference visit is offered for my convenience and I am able to cancel and reschedule with a different practitioner for an in-person appointment if I desire. I also acknowledge that sensitive medical information may be discussed during this Telehealth Video and/or Audio Conference visit appointment and that it is my responsibility to locate myself in a location that ensures privacy to my own level of comfort. I also acknowledge that I should not be participating in a Telehealth Video and/or Audio Conference visit in a way that could cause danger to myself or to those around me (such as driving or walking.) If my provider is concerned about my safety, I understand that they have the right to terminate the visit.
	Patient Questionnaire
	What is the reason you are in need of medical equipment? Please provide a brief medical history. In what year did your symptoms start?

	Please describe any pain including location and level from 1-10:

	What mobility equipment do you have and why is your current equipment not functional? If you have a Manual Wheelchair and can no longer propel it, please specify why not:

	Do you currently have any pressure sores, or a history of pressure sores?

	Please provide the details of any falls that you have experienced. (When, where, what happened, any injuries) When was your last fall?

	How do you transfer (e.g. from bed to chair)? Are your transfers safe? Does a caregiver assist with transfers? Do you use an assistive device to transfer?

	Do you have incontinence? If yes, what supplies do you use? (Diapers/briefs/pullups/pads, catheter, ostomy):

	Please describe any contractures or deformities that you have:

	Signer is Beneficiary:
	Beneficiary Representative:
	Relationship to Beneficiary:
	Signer's Address:
	Reason Beneficiary cannot sign:
	Beneficiary or Representative Signature:	Add/Edit Signature
	Would you like to login to your Patient Portal? (email required)
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