Cerbo – Integration – Signup 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Time Zone* AKST HST PST MST CST EST Office Phone*Office Fax*Office Email* Email used for patient contact* Medical Director* First Last **Medical Degree / licensure** Medical Director Email* Office Contact* First Last Office Contact Phone*Office Contact 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 $5 resource charge per 1000 active patients Basic Integration MessengerPro Integration Elite App Integration HiddenPortal Phone Portal Phone $25 SETUP (+$10 per User Per Month) Elite Add-onsThere are not setup fees for Elite Add-on integrations - we need to update our formWhat Elite Options do you want turned on? Portal Phone Zoom 3rd Party Payment System MindBody Hubspot Acuity Availity - Insurance System Ecommerce Integration Portal Phone SetupNumber of Dedicated Phone Lines 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 every 1000 active patients in your Cerbo system 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* Important You will get instructions in a follow-up email for confirmation and full authorization for Cerbo. Total $0.00 Please share any special details we should know.What custom app;ications 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*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.