New Holter site checklist

New Holter site checklist.

We’re looking forward to partnering with you. Please fill in all fields and submit.

Your contact details

Name

First Name

Last Name

State

Clinic details

Clinic name

Clinic contact name

First Name

Last Name

Clinic email

Clinic phone number

(include area code)

(###)

###

####

Use this contact information for onboarding?

Yes

No (add name and email of contact for onboarding in text box)

Use this contact information for invoicing?

Yes

No (add name and email of contact for invoicing in text box)

How many FTE GPs at clinic?

(reminder; 1 Holter device per 5 FTE GP)

Reporting doctor

If Local AHC doctor, provide the following:

Local AHC doctor name:

First Name

Last Name

Doctor provider number

Doctor email address

If National AHC doctor, please complete this form and follow instructions after hitting SEND

Billing model

Will you be providing an echo service at this clinic as well?

Yes