New Client Portal Information

Surgeons who meet and agree to the following criteria will be able to participate and receive potential patient leads:

Surgeon is actively listed in the SI-BONE.com “Find-A-Doctor” search listing
Trained Surgeon’s staff will participate in a brief online portal training
Trained Surgeon’s staff will access potential patient leads via a secure portal
Trained Surgeon’s staff agree to contact potential leads within 24 hours

These commercials/advertisements will direct patients to a call center operated by TrackableMed, which will collect information about the patients who call in and offer to have an iFuse surgeon’s office follow up with them to set up an appointment. Patients who call into the call center will be provided with a list of 3 surgeons to choose from based solely on proximity to their location, consistent with the list that would be provided by our “Find-A-Doctor” website surgeon finder. The patient will select 1 surgeon from the list of 3 provided and then TrackableMed will send that patient’s information to that surgeon’s office via a tracking portal.”

SI-BONE seeks to include any surgeon participant who meets the qualifications/criteria for participating in our “Find-A-Doctor” search listing in this program unless surgeon has chosen to opt-out of this program or has not confirmed they would like to opt-in. SI-BONE imposes no requirements on the manner in which the surgeon participant provides services to patients, except that ….[2, 3, 4].

*Surgeons have the opportunity to change their election at any time by completing a new document.

OPT-IN or OPT-OUT*

OPT-INOPT-OUT

I Trained Surgeon's Name WOULD LIKE TO RECEIVE information for prospective patients calling in from Si-BONE's consumer marketing campaign and commit that my staff will follow up on these prospective patients as defined.

Trained Surgeon's Signature (OPT-IN)

Date (OPT-IN)

Date

I Trained Surgeon's Name DO NOT WANT TO RECEIVE new patient leads from Si-Bone's consumer marketing campaign.

Trained Surgeon's Signature (OPT-OUT)

Date (OPT-OUT)

Date

Reps Name:*

First NameLast Name

Reps Email Address:*

example@example.com

Market*

Office Name:*

Location Name:

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Office Contact Name:*

First NameLast Name

Office Contact Email:*

example@example.com

Alternate Office Contact Name:

First NameLast Name

Alternate Office Contact Email:

example@example.com

Participating Provider's Name:*

First NameLast Name

Provider's Email:*

example@example.com

Does the provider accept Medicare?*

YesNo

Does the provider accept Medicaid?*

YesNo

Does the provider accept Aetna?*

YesNo

Does the provider accept Anthem?*

YesNo

Does the provider accept BCBS?*

YesNo

Does the provider accept CIGNA?*

YesNo

Does the provider accept Humana?*

YesNo

Does the provider accept United?*

YesNo

Additional Names of Participating Providers(At Same Location):

SI-BONE Broadcast Commercial Advertising Distribution

OPT-IN or OPT-OUT

Trained Surgeon OPT-IN:

Trained Surgeon OPT-OUT:

New Office Portal Information

Office Location Information