ICANotes Electronic Health Records Service Agreement
Please print this document and fax it to 443-992-4239. Download PDF Version here.
Internet Fees: $149.50/month for 1 prescribing clinician and an administrator + $150 setup fee. Additional prescribing clinicians $99 per month, non-prescribing clinicians $69 per month. Setup fee required for every clinician. Groups of 4 or more clinicians earn 1 additional administrative user. Groups of 8 or more clinicians qualify for special pricing, please consult business office 866-847-3590 xt. 3
Clinical users have full use of program, Administrative users cannot generate clinical reports but may have ability to enter certain patient demographic and non clinical data.
ICANotes will supply confidential passwords to each user. ICANotes reserves the right to examine the user database periodically.
If a user is dropped from the group and a new one is desired a new password must be issued and the old password must be expunged.
For billing purposes all users within a group must have the same billing dates regardless of when the individual users established service. No prorated charges are available.
An automatic monthly charge via credit card or bank transfer agreement is necessary. Other special arrangements must be made with ICANotes. A 15 day advance notice of cancellation is necessary. Subscribers wishing to cancel service should advise ICANotes at least 15 days before the end of their monthly period to avoid a new monthly charge.
ICANotes regularly backs up Patient Data and will provide patient data CD’s for any subscriber wishing to terminate service for a fee of $65 per CD. Users wishing to backup or upload data will be charged prevailing labor fees.
Each user must indicate the exact appearance of their letterhead as it will appear on all clinical documents.
I understand and accept the above conditions.
Signature___________________________________ Date_________________
Practice Name____________________________________________________
Clinicians Name __________________________________________________
Address ________________________________________________________
City,State, Zip ____________________________________________________
Telephone ______________________________________________________
Other Information to be included _______________________________________________________________
Email Address ___________________________________________________
Credit Card Information
Name as it appears on Card _____________________________________________
Billing Address _______________________________________________________
Credit Card # __________________________________________ exp______/______
CSV Code __________ (located on back of credit card)
Or
Checking Account
Name on Checks______________________________________________________
ABA Routing Number__________________________________ As it appears on checks between colons, example :7675579932:
Account Number__________________________________________ You can also fax a voided check with your service agreement.
PLEASE PRINT AND FAX THIS FORM BACK TO 443-992-4239
I _________________________________ authorize ICANotes to make monthly charges to my credit card in the amount of $ ___________ . I understand that I may cancel service upon giving 15 days notice in accordance with the agreement established above. My monthly period will begin on the _________ day of each month beginning ________________________.
Please contact us with any questions regarding this application at 866-847-3590 ext 3
Training and technical information is available by calling 866-847-3590 ext 1.
Thank you for your business.
PLEASE FAX THIS FORM TO 443-992-4239.