Cerbo – Integration – Signup Basic Medical Practice InformationName of Medical Practice* Medical Office Website* Medical Office Website - About page* URL for patient store Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United States AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Time Zone* AKST HST PST MST CST EST Office Phone*Office Fax*Office Email* Office Contact* First Last Office Contact Phone*Office Contact Email* Email used for patient contact* Medical Director* First Last **Medical Degree / licensure** Medical Director Email* Office Logo*Accepted file types: jpg, png, Max. file size: 64 MB.Cerbo (MDHQ) InformationMD-HQ.com URL Provider Portal* MD-HQ.com URL Patient Portal* How many years have you been on Cerbo?How many years have you been on Cerbo? Cerbo Integration TypeIntegration Type***The Free Basic Integration is for practices with less than 1000 active patients. Every 1000 active patients does incurs a $10 resource charge per 1000 active patients Pro and Elite Integrations pay $5 per 1000 active patients. ENTERPRISE is for Practice with more than normal users on Elite Applications, Practice that have more than 10,000 active patients in the Cerbo system. Practice that require a special connection into an application and has special needs ENTERPRISE * indicates additional charges may incurs Basic Integration MessengerPro Integration Elite App Integration Enterprise* Future Upgrade to Pro ($999), Elite ($1500) & Enterprise ($2500) is done at our Non-Discounted Rates (*Enterprise are required to be on the Enterprise Plan), Yes I understand HiddenPortal Phone Portal Phone $25 SETUP (+$10 per User Per Month) Pro & Elite SMS TextingDo you plan on using the SMS Texting feature? Yes No FxMedSupport Cerbo SMS Texting System --> Twilio Update The below information is required due to the new regulations around automated text messages. Please complete the form with your current business information so we may register your business with the Twilio system, create the appropriate brand as well as campaign with your FxMedSupport system connected to the Twilio system phone number. Effective July 5, 2023, all 10DLC phone numbers used to send SMS and MMS messages to U.S. phone numbers must be fully registered to an approved campaign under your brand. Messages sent using unregistered phone numbers will be subject to a gradual increase of message blocking by Twilio, beginning on July 5, 2023, ultimately leading to a full block of all unregistered U.S.-bound messages sent after August 31, 2023 Effective 06-07-23 Any A2P Campaign registrations are subject to a new vetting process, which includes a One-time $15 campaign vetting fee. Low Voulme If you have a Tax ID (EIN) and low traffic requirement (less than 6,000 messages per day), Low Volume Standard Brands can be used for mixed messaging campaigns with multiple use cases, multiple numbers per campaign, and higher throughput than Sole Prop Brand Registration $10 Standard Volume Tax ID (EIN) and higher traffic requirement (more than 6,000 messages per day), Standard Brands can be used for multiple use cases, multiple numbers per campaign, and higher throughput. Brand Registration $55 US A2P Reoccurring Monthly Campaign registration fees: Low Volume Branding Brand Registration $10 (Twilio Fee) Campaign $5/month (Twilio Fee) Standard Volume Brand and Campaign Brand Registration $55 (Twilio Fee) Campaign $10 Monthly (Twilio Fee) You will be charged the one time fees and acknowledge that your monthly fee will go up as well ***Accounts that do not complete this consent for us to be in compliance with your account with Twilio will no longer be able to send text messages***** Agree to SMS Texting Policies and Billling Yes I understand and Agree Elite SMS TextingBusiness TypePartnershipCorporationCo-operativeLLCNon-Profit CorporationEINBusiness Registration Identifier Will you ever send more than 6k SMS in a Day if Yes there is a monthly service Brand charge of $55 added by Twilio? Yes No Authorized Representative First Last Authorized Representative Email Job PositionDirectorVPGMGeneral CounselCEOCFOOtherElite Add-onsWhat Elite Options do you want turned on? Portal Phone System lifeFile Compounding Pharmacy Integration Payment Depot Payment Gateway MindBody Bi-Directional HubSpot Bidirectional Authorize.Net Payment Gateway US Pay Payment Gateway Acuity Scheduling Zoom Video Availity Insurance Insurance Verification System WordPress Zapier QualityMetric Inc. Am I Healthy WordPress Shopify Cerbo Pro BigCommerce Cerbo Pro Woocommerce Cerbo Pro Estimate – Auto Pay Clover Payment System Integration Thinkific Course Platform Gravity Form Jot Form TypeForm Portal Phone SetupNumber of Dedicated Phone Lines Quantity Price: $10.00 Quantity Cerbo Phone Dedicated Line SetupCerbo User NamePersonal Cell Number HiddenMINDBODY BI-DIRECTIONAL MINDBODY BI-DIRECTIONAL $250 setup Fee HiddenZoom Zoom HiddenCustom Payment Gateway Custom Payment Gateway HiddenHUBSPOT BIDIRECTIONAL HUBSPOT BIDIRECTIONAL $50 setup Fee HiddenE-commerce - Cart Integrationhttps://fxmedsupport.com/supplement-store/ E-commerce - Cart Integration Set-up $250 HiddenACUITY SCHEDULING ACUITY SCHEDULING $50 setup Fee Active Patient System Resource Fee* Yes, I acknowledge that there is a $10 system resource fee for Basic Accounts & $5 Resource Fee For Pro and Above Accounts. Every 1000 active patients in your Cerbo system is a New Tier If you select Basic Integration and do not complete the setup process in the initial 30 days we will deactivate the setup process and not be able to rejoin at the Basic Free Membership. If you are unsure of wanting the servies at this time please do not sign-up. Once you sign-up our team goes to work and on average it takes approx 2 Hours to build an account so when you sign-up and do not activate the API it is a lot of invested time. Thank you FxMedSupport HiddenCerbo VA PlacementHiddenDo you want to be matched with a VA Yes No HiddenHow manyPlease enter a number from 0 to 10.Payment EncryptionCredit Card #* Credit Card Expiration Date* Credit Card Security Code* Credit CardPlease check if you have activated a Stripe feed for your form. Important You will get instructions in a follow-up email for confirmation and full authorization for Cerbo. Total $0.00 Basic Integration Complementary core practices under 1000 active patients $10 per every 1000 active ptsPro Integration Reoccurring monthly fee $75Elite Integration Reoccurring monthly fee $125Please share any special details we should know.What custom appications are you thinking about?I Agree to all Sign-up and Integration Terms* Yes What Year is it* Referral sourceSo we can send thanks to those who support FxMedSupport Signature* Reset signature Signature locked. Reset to sign again TermsFxMedSupport odoes not impose contracts on our members, and members are free to cancel their membership at any time. We wait 48 Hours to start the integration process and or charge your account. After 48 hours the initial integration fee is not refundable. Written notice is required to cancel a membership. Members must submit cancellation TICKET 30 days prior to their next payment date. Most memberships are prepaid and are month to month. Memberships in good standing automatically renew at the end of the 30-day next membership cycle. There are memberships that are affiliated with a Y program (example: Diabetes Prevention) or initiative which includes prepaid or complimentary membership for a set period (example: 3 months). These membership types do not renew at the end of the membership cycle. The membership cycle begins the day the member joins and auto renews every 30 days provided the member is in good standing and does not owe a balance. Members can prepay for annual, 6-month or 3-month membership cycles. These membership default to renew every 30 days at the end of the prepaid cycles provided the member is in good standing and does not owe a balance. Memberships do not automatically cancel due to inactivity. Members must provide written notice to stop their membership from automatically renewing. It is the responsibility of the member to bring any billing discrepancies to the FxMedSupport’s attention within 60 days after they first appear on financial statements. After 60 days, the member’s right to dispute any discrepancies is waived. Member Initiated Cancellations Members who wish to cancel within 30 days of joining must do so in writing. Members are NOT subject to a refund. Members who wish to cancel their membership after 30 days must do so in writing . The cancellation will be processed prior to their next draft and the membership will remain active through what the member has paid. We do not prorate remaining monthly membership value. FxMedSupport Initiated Cancellations When Y staff terminate a membership that is expected to automatically renew for reasons such as member behavior, staff error, or another circumstance, refunds are issued back to the original payment method. If the original payment method is no longer active or was in the form of a check, cash or ECT payment, the refund will be processed as a check to be mailed to the member’s address in the system.