New Client Information Form
Facility / Organization Information
 (6 users required to gain org access)
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 users who wish to not use a credit card as long as they have purchased 20+ access codes. 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.

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.
• Unless otherwise stated all training is done at client site.
• All reasonable travel expenses and lodging expenses associated with training will be invoiced separately.
• Agreement and pricing have been determined for a month-to-month charge.
• 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.

End User License Agreement:

     Accepted by user at sign-up      CLICK to complete BAA
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714 Spirit 40 Park Drive - Suite 140
Chesterfield, MO 63005
(636) 812-0242