Cerbo – Integration – Signup

Basic Medical Practice Information
Name 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
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) Information
MD-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 Type
Integration 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
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
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Portal Phone

Portal Phone $25 SETUP (+$10 per User Per Month)
Pro & Elite SMS Texting
Do 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 Texting
Business Type
EIN
Business 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 Position
Elite Add-ons
What 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 Setup
Number of Dedicated Phone Lines Quantity
Price: $10.00
Cerbo Phone Dedicated Line Setup
Cerbo User Name Personal Cell Number
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MINDBODY BI-DIRECTIONAL

MINDBODY BI-DIRECTIONAL $250 setup Fee
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Zoom

Zoom
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Custom Payment Gateway

Custom Payment Gateway
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HUBSPOT BIDIRECTIONAL

HUBSPOT BIDIRECTIONAL $50 setup Fee
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E-commerce - Cart Integration
https://fxmedsupport.com/supplement-store/

E-commerce - Cart Integration Set-up $250
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ACUITY 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
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Cerbo VA Placement
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Do you want to be matched with a VA

Yes

No
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How many
Please enter a number from 0 to 10.
Payment Encryption
Credit Card #*
Credit Card Expiration Date*
Credit Card Security Code*
Credit Card
Please 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 pts
Pro Integration Reoccurring monthly fee $75
Elite Integration Reoccurring monthly fee $125
Please 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 source
So we can send thanks to those who support FxMedSupport
Signature*
Terms
FxMedSupport 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.

FxMedSupport

Cerbo – Integration – Signup

Basic Medical Practice Information

Cerbo (MDHQ) Information

Cerbo Integration Type

Pro & Elite SMS Texting

Elite SMS Texting

Elite Add-ons

Portal Phone Setup

Cerbo VA Placement

Payment Encryption

Terms

Member Initiated Cancellations

FxMedSupport Initiated Cancellations

Friday Connection Questions

Newsletter Sign-up

Testimonial

Cerbo User Name	Personal Cell Number