Client Information

Client ID:

Support Type: Restricted

Support Number: 800-423-8836

ONC Certification **

Product: American Medical Software - EMR

Granted: 12/15/2010

Expires: 12/31/2012

Versions: 22 / 23

Certificate #'s:
CC-1112-125863-1 RxNT
CC-1112-125863-2 NewCropRx

UPDATES

RESOURCES

AFFILIATE VENDORS

Personalization and Registration Form


PLEASE ALLOW UP TO 10 BUSINESS DAYS TO PROCESS YOUR REQUEST!

Fill out the following form so that we may personalize your computer system. The personalization information affects the address printed on insurance forms, statements, and various other areas in the software. Optionally, you can choose to have a different address print on your insurance forms from what prints on your statements. You can only have one statement address. Use the boxes below to fill out your address(es). NOTE: Only thirty (30) characters are allowed for each line of the address.


* Denotes a required field.

Client ID * Version * Files Directory (if applicable)

Statement Personalization *
Check here if you do not wish to change your statement personalization.
Practice Name
Address
City, State, Zip
Phone


Insurance Personalization *

Note: New 5010 specifications require both your 5 digit zip code as well as your 4 digit zip code extension for pay to addresses.

Check here to use the first three lines of your statement personalization.
Practice Name
Address
City, State, Zip


Check here to add an additional insurance personalization.


Shipping Address (no P.O. Boxes)
Do not change shipping address.
Change to statement personalization above.
Change shipping address.
Name
Address Line 1
Address Line 2
City, State, Zip


Mailing Address
Do not change mailing address.
Change to shipping address above.
Change mailing address.
Name
Address Line 1
Address Line 2
City, State, Zip


Please email my personalization to:*

I agree that the above is true and correct. *

Please verify that your Client ID and email address are correct. We can not process any personalization requests without a proper ClientID and email address.

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