Avaz MD - Get Started - Free Olympus DS 4000

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IT IS EASY!
- Calling us or completing this form obligates you to absolutely nothing.
- Once you start with us, you may cancel anytime**.
- Information provided is confidential. See our privacy policy.

AFTER YOU COMPLETE THIS FORM ...
... your personal account manager will contact you and ask you
for your templates / work-types.
... we will ask you for the names of your staff
requiring access to Avaz MD.
... and you' re ready to put us through the paces.

Please complete ... Please complete as many questions as possible. It will help us give you the best initial proposed solution for your specific operation.

Your Name	Required
Company / Practice Name
City & State
Telephone	Required
E-Mail	Required

Your Specialty (s)
Secondary
Other

Is this a new practice?	Yes No
Do you have more than one location?	Yes No
Size of your practice:

Preferred method of dictation	Telephone Hand-held recorder PDA / other hand-held devices Tablet / PC / Airless dictation We use a combination of methods

Do you have an EMR system?	Yes No I don't know
Can you electronically export patient demographics / ADT?	Yes No I don't know
Do you mail and fax completed reports to 3rd parties?	Yes No I don't know
Are you required to share / provide electronic records with 3rd parties (such as a insurance company)?	Yes No I don't know

Would you like to retain some or all of your in house transcription staff?	We have no in house staff Retain some staff Retain all, just interested in your technology Not sure, please advise

Notes / Comments


	HIPAA \| Privacy Policy \| Service Policy & Disclaimers () Terms and conditions apply. Some options may require implementation fees and time. (**) Offer available to US customers only. Each dictating author must dictate at least 300 reports with Avaz within a six-month period. Once 300 reports have been completed and Avaz has received payment for such reports, Avaz will reimburse that dictating author for the cost of one hand-held recorder up to US$400.00. Offer good for only one unit per dictating author.


	Avaz Group LLC. All rights reserved.

Avaz, Avaz MD and ATERA are registered trademarks of Avaz Group LLC.

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