Clinic Intake Form

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Clinic Intake Form

This form is used to request a TheraPlan EMR service agreement. We are an EMR in the business of offering Complete Therapy Practice Solutions. Complete this form to start your journey with us!

Clinic Name

Clinic Website Address

Phone

Email

Fax

Contact First Name

Contact Last Name

Specialties Offered

ST

ABA

PT

Mental Health

OT

Other

Number of Providers

Number of Admins

Group Taxonomy

Group Medicaid Number

Group Medicare # (PTAN)

Tax ID

Group NPI

Clinic Street Address

Street Address 2

City

State

ZIP / Postal Code

Services Requested - Payroll is included. All other services listed have additional usage fees or monthly costs.

All

Medicaid Eligibility- TheraCheck

SMS Texting- TheraReminders

Payroll

Integrated Fax- TheraFax

OpenPM (Practice Management)

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