Form Builder

I agree to the statement above.

Name

Department/Clinic (if applicable)

Office Physical Address

Street/Suite #

City/State/Zip

Office Phone

Home Phone

Cell Phone

Billing Address (if different than Office Address)

Which PCME Services are you registering for?

During requested service hours and for $85 per month plus tax (billed quarterly), I request:

24/7 Call Service

Phone Number to call

Office
Home
Cell

Text Messaging on HIPPAA-Compliant App

(Note: This service requires the use of a smart phone/device and the downloading of a HIPAA-Compliant app. A
personal email address is required to set up the account. Please, no office manager email addresses or addresses
shared with other physicians. Text messages will not be sent in any other manner.)

Monthly on-call schedules should be submitted to PCME by the 20th of the preceding month. All changes to a member physician’s schedule or contact information must be submitted in writing.

Text Messaging on HIPPAA-Compliant App

Physicians Name

Secondary Contact Method

Group you will be taking calls with

Office Address

Office Hours

Office Number

How do you want to be contacted after 10 pm?

How do you want patient calls to be handled DURING office hours?

How do you want patient calls to be handled AFTER office hours?

Will you be taking AFTER office hours outside lab call?

Do you want calls from healthcare nurses?

Do you ever want your phone number(s) shared with doctors or hospitals?

Are there any special instructions on how to handle second or third calls from the same caller?

If you have any nurses who will be taking calls for you please add them below. (please provide name and primary way to contact)