Secure Forms Order

Introduction and Purpose

Mediprocity is a HIPAA compliant communication provider. We supply encrypted secure messaging and secure forms via a web client and mobile apps. Mediprocity is HIPAA compliant for both messaging and forms. Mediprocity provides HIPAA compliant communication to skilled nursing care in accordance with HIPAA and HITECH guidelines per the Omnibus Rule of 2013.

Scope & Procedure

This form is a follow-up on a Request for Information to begin using “Secure Forms”. To answer this RFP please complete the attached Response Form so that we may begin the process to build out your secure forms library.  Your forms estimate to customize will be included in your Secure Forms RFP.
Basic & Deluxe plans are per (1) organization only.  Pro plan may have up to (2) unique organizations.

Basic    $30  (1-3 forms)
Deluxe  $60  (4-20 forms)
Pro        $100  (21-100 forms)

How Many Users? 

A user is defined by who you would like the form to be sent.  You may have up to 10 people per form on Mediprocity.
You do not need to know the users at this time, this is simply to give us a gauge on setup time.
Form requested format:        PDF   HTML  CSV (Excel)  XML    Plain Text    Not Sure At This Time

List (3) dates to request your 1-hour training session






Mediprocity takes credit cards and it is the preferred method of payment. All super users may enter from their profile. Mediprocity can invoice users who wish to not use a credit card.

Your credit card will be charged monthly for the services with a receipt mailed to you directly.

You may also be invoiced for all services, which require a NET 30 days. If an invoice runs to 60 days late the accounts will be deactivated until payment has been received. 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.

• Client agrees to sign Mediprocity Business Associate agreement upon initial use.
reset signature
Use your finger or mouse to sign your signature in the box above.

Today's Date:

Please reference your Secure Forms proposal in this box:


Please upload your Company Logo here (or) please send a copy to

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