AZZLY Quick Start Plan

1
What services do you offer or plan to offer?* This field is required.
Mental Health
Behavioral Health
Substance Use Disorder
2
Place of Service* This field is required.
In Person
Virtual (Telehealth)
In Person/Virtual
Off Site Locations
3
What state(s) will you operate in?* This field is required.
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
4
What Levels of Care?* This field is required.
Outpatient
Residential
Inpatient Detox/Psych
5
What Features Are Required For You?* This field is required.
Telehealth
Bed Board
Patient Portal
RCM
E-Prescribing
EHR
Integrated Claims
Reports/Analytics
Other
6
What “Other” Features Are You Looking For?
Huge
Large
Normal
Small
Ok
Ok
7
Do you use an EHR currently?* This field is required.
YESNO
8
How many staff do you have?* This field is required.
Licensed Providers
Support Staff & Billers
9
Are you interested in using AZZLY for medical billing?* This field is required.
YESNO
10
Do you accept insurance?* This field is required.
YESNO
11
Do providers prescribe any medications?* This field is required.
YESNO
12
Number of licensed prescribers?
13
We're glad you're here, what is your full name?* This field is required.What is your full name?
First Name
Last Name
14
How can we contact you?* This field is required.
Please enter your phone
Please enter your email
Company Name
Website
15
What is your preferred form of communication?* This field is required.
Please Select
Please Select
Email
Phone
Text
16
Attention: A Negative Value Was Detected

Please correct the number of licensed providers, support staff & billers, or number of licensed prescribers that you entered. Once correct you can resubmit this form to receive your customized quote. Thank you.
17
Map Easy Start Plan
YESNO
18
Total Price Estimate
Should be Empty: