Get Started With EZClaim!

SELF-SERVICE SUBSCRIPTION
How many BILLING USERS do you need?
Please enter a number greater than or equal to 1.
How many COMPANY FILES do you need?
Please enter a number greater than or equal to 1.
How many PORTAL USERS do you need?
Please enter a number greater than or equal to 0.
COST for BILLING SOFTWARE:
COST for COMPANY FILES:
COST for PORTAL USERS:
TOTAL COST (Per month):
Contract Details

Note: Any free months start at the time the order is submitted.
Included Services
- Designated Onboarding Coach or self-serve option
- Training during Onboarding
- Daily backup of cloud data
- Online and live support resources
- Statement customized with your company logo
- EZClaimPay (only pay merchant fees)
- Storage Space: 1 GB is included, $3/month for each additional GB
EDI Services

We suggest contacting TriZetto Provider Solutions or Waystar. Another option is to continue to utilize your existing EDI services.
Available Services

Prices subject to change
- Additional user licenses are $104.00 each monthly
- Staff training after the Onboarding Graduation will be available as recorded webinars. Individual training sessions are available with expert EZClaim Trainers at $100 per session.
- Additional Company Files: $30/month
- Other Services: $200/hour (Example: Assistance with security assessments or anything else outside our standard Onboarding procedure.)
- Practice Fusion Integration: $0.10 per superbill
- BillFlash Electronic Statements & Payment Services

EZClaim Account Owner (Required)

This person has full control of the account (including password authority)
Important - Your cell phone is required for EZClaim Portal Account activation.
Account Owner Company:*
Account Owner Specialty:*
Account Owner Name:*
Account Owner Title:*
Account Owner Address:*
Account Owner City:*
Account Owner State:*
Account Owner Zip:*
Account Owner Phone:*
Account Owner Cell Phone:*
Account Owner Fax:
Account Owner Email:*
Contract Sign Date:*
MM slash DD slash YYYY
Admin Level Authorities (Optional)

The following users have the ability to receive password information and to request password changes
Admin 1 Email:
Admin 1 Name:
Admin 2 Email:
Admin 2 Name:
Point of Contact (Required)

This person will be the primary person during setup of the program.
Primary Contact Name:*
Primary Contact Phone:*
Primary Contact Email:*

Training Contact (If Different)

This person will be the primary person to contact to coordinate training. If different than the primary point of contact.
Training Contact Name:
Training Contact Phone:
Training Contact Email:
Hidden
Onboarding (Both options are included with your subscription)*
- I would like an Onboarding Coach to contact me for next steps (included through Onboarding Graduation)
- I select the self-serve onboarding option and would like email instructions (available for new customers only)
NOT IN USE as of 03/08/2021
EZClaim Configuration Setup (Required)

In this section enter your Company File Name (or the names of your clients if a billing service) in the first box.
Please enter a Clearinghouse and EMR (if applicable) in their respective fields.
Company Name(s)*
Clearinghouse:*
EMR:*
Claims
- Sending Professional Claims
Claims
- Sending Institutional Claims
Accept Advanced to Premier checklist*
- I have reviewed and accept the information outlined in the Advanced to Premier checklist
Terms of Service*
- I have reviewed and accept the information outlined in the Terms of Service
Account Owner Contract Signature:*
NOTE: If the account is canceled due to non-payment, a $50 reactivation fee will apply.
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Fill out the form below to get started with EZClaim!

EZClaim Self-Service: Purchase EZClaim Now!

Step 1 of 3 - Software Details

SELF-SERVICE SUBSCRIPTION

Contract Details

Included Services

EDI Services

Available Services

EZClaim Account Owner (Required)

Admin Level Authorities (Optional)

Point of Contact (Required)

Training Contact (If Different)

EZClaim Configuration Setup (Required)

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