measura.ai account registration
Consultant Service Provider In Good Company LLC DBA Measura.ai 5203 Chippewa, Suite 301 St. Louis, MO 63109
Referred by
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Referral Source
Referral's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Administrative Contact in Practice
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First Name
Last Name
Name of Practice
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Practice Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practice Email
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example@example.com
Practice Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
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Format: (000) 000-0000.
Practice Specialty
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Practice Specialty
Practice Type
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SNF
ALF
Private Medical Clinic
Hospital Based Clinic
Pre admission Testing [HOPD or ASC]
RTM/ RPM/ CCM
Other
Patients per day
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Patients/D
Percentage of patients private insurance
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Pricvate Pay %
Percentage of patients Medicare
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Medicare%
Percentage of patients Medicaid
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Medicaid%
Percentage of patients Self Pay
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Self Pay %
Percentage of patients HMO capitated
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Capitated %
Number of days per week full time
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Tax ID Practice
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Practice NPI #
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Medical Records Maintenance Acknowledgement
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The provider and the practice will maintain and archive all necessary patient signatures for samples sent from the practice location. The lab is not required to have these signatures. The provider and the practice acknowledge that it is responsible for obtaining the patient's signatures, consent, and medical information at the time of initial sample collection and keeping signatures up to date. Additionally, the provider and the practice acknowledge that the lab has the right to obtain a copy of the patient's signatures, consent, and medical information held on file at any time. Either Party may terminate this Agreement for any reason upon 30 days prior written notice to the other party. Upon termination of this Agreement, the provider and the practice shall immediately return to the Service Provider any property or Confidential Information in their possession, custody, or control. The provisions of this Agreement that by their nature shall survive termination (including, without limitation, the sections relating to intellectual property, confidentiality, limitation of liability, and indemnification) shall survive any termination or expiration of this Agreement. The provider and the practice understand this will remain in effect until the undersigned changes it.
Measura.ai Equipment and Payment:
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Net Revenue agreement between Practice [60%] and Measura.ai [40%] where practice bills and collects, settlement on a monthly basis. The practice maintain and name Measura.ai as an additionally insured on Property, Casualty, and Malpractice Insurance.
Practice acknowledgement immediate release of Panic Value:
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The practice acknowledges that lab results will be released to Measura directly before they are made available to the practice, except for panic values. Measura will process and analyze data on behalf of the practice to develop lifestyle coaching programs. Measura is not providing direct patient care. Any panic lab values will be immediately released directly to the "Contact for panic values" in the practice.
Who should receive immediate notice of lab or measura panic value and best way to contact:
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Contact for panic values
Staffing
I have or know of a local staff person who can function as a phlebotomist and be trained in full measura.ai testing, if measura.ai hires this staff person they will become a full time employee for measura.ai and I will not be able to use them during the measure.ai paid hours.
I expect that measura.ai recruits and hires the local staffing, I do not have a local staff person who can function in this capacity.
Name of staff person, email and best phone number:
Provider Name
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First Name
Last Name
Provider NPI #
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Provider Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Provider Direct Email
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example@example.com
Date
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Month
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Day
Year
Date
Hour Minutes
Provider Signature
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