top of page
Remote Care Today
1099 Consultant Name
1099 Consultant Affiliate Code
1099 Consultant Email
Practice or Business Name
Number of Medicare Lives
Number of Providers
Type of Demo
Remote Care Stage of request
Type of Industry Demo
CereSkills Stage
Address
City
State
ZIP
Decision Maker First Name
Decision Maker Last Name
Decision Maker Phone
Decision Maker Email
Office Champion First Name
Office Champion Last Name
Office Champion Phone
Office Champion Email
TYPE of Provider
Notes
EMR Type/Name
Person Signing the Agreement
Person Signing Agreement Email Address
Billing/Biller Name
If a 3rd party Biller is used, please list name/company name
Biller Contact Name
Biller Email Address
Recommendation Video for Enrollment Page
Outreach Campaign Provided
Outreach Campaign Provided by SHS
Start Now
Providers
What We Offer
Who We Are
bottom of page
