Agreement Addendum

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


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


Organization


$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


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.)


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


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:


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.

Agreement Addendum

Documents