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Unit Price Client Initials
Per provider/year $24
Telemedicine (Powered by Zoom) Per provider/month $39
Exercise Library Module (Powered by Exercise Pro Life) Per provider/month $19.95
Clearinghouse Fee
$0.39
$0.89
$0.89
$0.89
Per facility NPI/month $29
$0.39
$39
$0.39
$39
$0.39
ClaimStaker (Powered by Alpha II ) $65
Patient Statement Submission $0.94
Monthly minimum of $20 applies $0.25
E-Statements $0.30
INSYNC LOCKBOX SERVICES – PRICE LIST for RCM CLIENTS
Lockbox Setup Fee $500.00
Monthly Maintenance Fee $299.00
Wholesale Lockbox checks $0.75
Document Imaging $0.35
Paper EOB to ERA Conversion $0.75
Conversion Exceptions $0.35
$0.14
$0.14
Per email $0.07
Per concurrent user/month $50
Scanner with Insurance Card & Driver’s License OCR Integration Per scanner (paid in advance) $1,095
(SnapShell IDR w/.Net OCR Powered by Card Scanning Solutions Inc.) Additional charges (payable in advance ):
$95
- $45 shipping/handling $45
Electronic Signature Pad with Integration $395
(SignatureGem Backlit LCD 1X5 Powered by Topaz Systems Inc.) Additional charges (payable in advance ):
$95
$45
Agreement Addendum
Value-Added and Third-Party Products & Services
Transaction based eligibility plan. Transaction defined as each patient
eligibility check.
Exercise Pro contains a large exercise database in a variety of areas, making it a
great resource for physical therapists, athletic trainers and chiropractors. With
over 3100 exercises in a variety of specialty areas, it is an excellent tool for
delivery of home exercise and patient education.
UB-04 Submission plan with 500 transactions per month included
under facility NPI for $29. Each additional 500 transactions under
facility NPI billed at $29.
Real-Time Insurance Eligibility Check
(Unlimited /Provider) Individual NPI
Intelligent Data Capture & Auto Fill Scanner Software
(replacing the current OCR scanner. External camera required)
Optical Character Recognition (OCR) for extracting discrete data
elements from scanned Drivers License, IDs and Insurance Cards and
populating them directly into fields available on Demographics and
Insurance page.
Electronic LCD signature pad to capture patients' signature on custom
forms; eliminates the need to print and scan the forms back into the
system
(**NOTE: All signature pad devices are warranted by manufacturer for a maximum of 12 months from date of purchase. Devices returned other than for defect will be refunded, subject
to a 35% restocking fee.)
ASAM (6 Dimensions Assessment ONLY)
(**NOTE: by signing up for appointment reminders you will be set up for all three services Text Message Reminders are $0.14 for first 160 characters. Additional characters will be charged $0.14 for each additional
page.
Real-Time Insurance Eligibility Check
(Group NPI plan with 500 eligibility transactions per month included
under group NPI for $39. Each additional 500 transactions under group
NPI billed at $39.) Not all insurance companies accept group NPI.
QTY
Per provider NPI/month
Per Rendering Provider/month
Per provider/month
Per minute (phone)
Each additional page
Per text
- Initial setup fee of $95/scanner
Per Claim
$75
Group NPI/month
Per Practice/month
Per Check
Per Page
- $45 shipping/handling
- $149/scanner annual
maintenance & support fee
Unlimited Electronic Claims, ERAs and Secondary Claims from
Participating Payers.
- Initial setup fee of $95/sig pad
Per signature pad (paid in advance)
Per Practice/1 time setup
Paper HCFA Claim Submission Per practice/transaction
Worker's Comp HCFA claim submission with attached encounter notes Per practice/transaction
iHCFA Clearing House interface for Worker's Comp and No
Fault/Personal Injury HCFA claim submission with attached encounter
notes
Per practice/transaction
Per statement fee (1st pg)
Per statement fee
Per Claim
Per Group NPI/Transaction
(**NOTE: All OCR devices are warranted by manufacturer for a maximum of 12 months from date of purchase. Devices returned other than for defect will be refunded, subject to a 35%
restocking fee.)
Appointment Reminder Services (Powered by Alert Solutions)
One-time set-up fee of $95 applies (payable in advance); Monthly
minimum fee of $25 applies;
UB-04 Submission Transaction based plan. NOTE :
90 day notice to change of provider plan between per transaction and
500 transactions
Per provider/transaction
Per Transaction
Transaction based clearinghouse plan. Transaction defined as Claim
submission, Claim re-submission, and ERA.
NOTE: 90 day notice to change of provider plan between Transaction
and Unlimited
Per provider NPI/transaction
Transaction based eligibility plan using Group NPI. Transaction defined
as each patient eligibility check.
(**NOTE: This service requires office to capture valid email addresses for statements to be sent electronically. If email address is invalid, office needs to send paper statement manually.
- $149/signature pad annual maintenance & support fee
VER AUG-01-2016 Page 1
Unit Price Client Initials
Per fax line/month
Toll-Free Number $19Local Exchange NumberAdditional charges:
- Each add'tl page over 500 $0.10$95.00
Electronic Fax – Outbound (Powered by Interfax) Per page 0.12
Electronic Fax - Number Portability (Powered by Interfax) One-time Fee $40.00
InSync PM/EMR Application Hosting Services Per provider/month $50
Medication Management Package (inSyncRx) Per provider/month $35
$95
ePrescribing for Controlled Substances - EPCS (inSyncRx) Per provider (payable in advance) $150 **
**NOTE: This service also requires an additional $100 Identity Proofing fee payable directly to Exostar
Per provider/month $50
Data Import/Conversion (all services paid in advance )
Per practice $995
Per practice$5,000
Meaningful Use 2 (MU2) Attestation Services
Per Provider No charge
$85
$950
$50
$600
Per 65 character line $0.12
Request activation
Read Only Access (access your data
without having the capability to append any new records)
a. Independent attestation utilizing InSync self-help guides along with
ONC/CMS documentation.
**Setup Fee (payable in advance )
**or**
Annually per provider
Per provider/month
**or**
Annually per provider
Per provider/month
(calendar year from March 1st thru
February 28th.)
b. Monthly Monitoring & Attestation Assistance:
Concierge training and monthly monitoring of MU data to ensure
providers are meeting criteria set forth by CMS Includes assistance
from an InSyncHCS Meaningful Use Specialist working directly with the
provider/practice to enter data into the CMS portal for attestation. In
the event of an Audit, InSync HCS can support you with the required
information. Insync Direct - Origanization Account included in price.
c. MU2 Attestation Assistance Only:
Concierge level of assistance of our Meaningful Use Specialist to work
with the practice in entering data into CMS for attestation. This does
not cover support in case of an audit. Insync Direct - Organization
Account included in price.
Patient hand-outs in 18 languages and comprehensive doctor’s drug reference from GSDD; Allergy, Drug
and Pregnancy interaction review from GSDD, Comprehensive managed care formularies from
SureScripts, including Medicare Part D and Medicaid; and RxHub: managed care interface for all-
doctor drug history and electronic mail-order
Option A
Import of basic patient demographic, insurance master files, providers and referring
providers from .xlsx or pipe (|) delimited .csv
*Client will provide data in specified format.
*Only fields provided will be converted
Per email address /
month
Electronic Fax – Inbound (Powered by Interfax)
$25
Option B
Includes Option A plus the conversion of future appointments and clinical data which
includes patient charts, medical history, treatment history, lab results, insurance
records and other documents.
• All Clinical Data must be provided to InSync in PDF format. Any other formats will not
be converted. Data Index file may be required to name documents appropriately.
• Clinical Data is converted as PDF attachments in the document manager.
• This option includes up to 50 GB of data. Anything over 50 GB will incur an additional
cost.
*This fee is due to InSync. Your current software may charge for any data extractions. This is outside of the fees paid to InSync.
**All Data Migration/Conversion services are provided as a convenience for our customers. InSyncHCS assumes no liability with regards to the
accuracy, integrity or validity of migrated or extracted data.
InSync Direct - Organization Account / Individual Account
Radiology Interfacing
Value-Added and Third-Party Products & Services (CONT)QTY
Setup and Training on e-prescribing and prescription management for controlled substances. Requires Identity Proofing
and two-factor authentication.
- One-time setup fee
(Powered by Secure Exchange Solutions)
Practice/ Individual email account using the DIRECT protocol for
securely sharing healthcare information between referring providers;
Required for Meaningful Use Stage 2 (one per practice)
$15
($165 / year if
paid in advance)
Up to 500 inbound pages included per fax line
Medical Transcription
VER AUG-01-2016 Page 2
Organization
Unit Price Client Initials
$995
Lab/Imaging Integration
Request activation
$95/hour
$1,250/day
$95/hour
$95/hour
$180/hour
$180/hour
***PLEASE EMAIL COMPLETED FORM TO: [email protected]
Business Legal Name:
Customer ID:
Address:
City, State, Zip: Name:
Phone:
Fax:
Email:
Contact Name:
Address:
City, State, Zip:
Phone: 877.246.8484
Fax: 732.200.0654
Sales Person:
2 Onsite Training and services are subject to billing of airfare at actual cost.
Airfare additional2 (a minimum of 3
days need to be purchased in order
for onsite.
Custom engineered HL-7 connector interfaces the InSync EMR or PM with your network's Health
Information Exchange or Accountable Care Organization database. Unidirectional or bi-directional
interfaces are possible, subject to the constraints of the target platform.
Custom quotation
HIE/ACO or Third-Party Software Interfacing
Client Registration API Website LinkLink established on client website for patient registration.
Setup and Configuration : InSync
certified implementation specialist will work with practice to collect
requirements/content and perform software setup and configuration
changes. Purchased hours will include client phone sessions to gather
information, as well as, dedicated configuration time separate from
phone sessions.
4-hour minimum
(payable in advance )
Practice Consulting Services (Remote or Onsite)
Let us audit your practice clinical and financial workflow, and
recommend a series of possible improvements and industry "Best
Practices" designed to help you achieve optimal performance and
efficiency.
Note: Onsite services may incur additional charges for Travel &
Lodging.
PM Training Fee (Remote Billing Training) :
EMR Training Fee (Remote Clinical Training) :
IT Consulting Services (Remote)
Includes any IT related services required/requested by clients for
maintenance and administration of onsite application servers.
10-hour minimum
(payable in advance )
Value-Added and Third-Party Products & Services (CONT)
QTY
For Securing Sensitive Information on Onsite servers
Certificate purchased separately through Domain Name Registrar
Electronically send lab orders and receive results with the ability to interface with over 50 labs across the
country, including LabCorp and Quest Diagnostics; Auto-delivery reduces need for faxing, scanning and
uploading attachments
(Training can be delivered in 2 hour
increments.)
(payable in advance )
One-time Fee
(payable in advance )$995
SSL Certificate Installation by InSync
InSync certified trainer will remotely (via Zoom) train all staff on
established software configuration and workflows. A reliable internet
connection is required.
Training Fee (Onsite): InSync
certified trainer will go to practice location and train all staff on
established software configuration and workflows.
InSync Healthcare Solutions LLC
ATTN: Finance
8408 Benjamin Road
Tampa, FL 33634
Date:
Title:
(Please Note: By signing this document you are
confirming that you are authorized to make
commitments on behalf of the medical practice and
affirm acceptance of the software “as-is”, that the
signor had satisfied themselves the software is suited
for their intended purpose.)
Authorized
Signature:
4-hour minimum
(payable in advance )
1 All Data Migration/Conversion services are provided as a convenience for our customers. InSyncHCS assumes no liability with regards to the accuracy,
integrity or validity of migrated or extracted data.
Provider Name:
VER AUG-01-2016 Page 3
Bank Account Debit/Credit Card Form
IHS offers two automated payment options for charges associated with our services. Please choose one by completing the appropriate section below and emailing to: [email protected]
CUSTOMER ID:
ACH AUTHORIZATION:
Name on Account: Please debit my (Please check one) Checking Account (Enclosed voided check) OR Savings Account (Complete info below)
Routing / ABA No: Bank Acct #
Authorized Signature: Date: Authorized Signature: __________________________________________________________________Date: _______________________
CREDIT CARD AUTHORIZATION:
Credit Card Type: (Please check one) Visa Master Card American Express
Cardholder Name: Credit Card Account #
Expiration Date: Security Code: ( 3 digits on back of Visa OR 4digits on front of AMEX)
Cardholder Billing Address: BEING THE CARDHOLDER OR CORPORATE OFFICER, BY SIGNING BELOW I AGREE TO PAY, AND SPECIFICALLY AUTHORIZE IHS TO CHARGE MY CREDIT CARD FOR THE SERVICES/PRODUCT PROVIDED. I FURTHER AGREE THAT IN THE EVENT MY CREDIT CARD BECOMES INVALID, I WILL PROVIDE IHS WITH A NEW VALID CREDIT CARD, TO BE CHARGED FOR THE PAYMENT OF ANY OUTSTANDING BALANCES OWED TO IHS. Signature: Printed Name: Date:
Privileged & Confidential Insync Healthcare Solutions
VER 1.1 Aug 2017
Initial here if you give authorization to be put on auto-pay
for future invoices.