How Can We Assist?
*
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Add A Provider
Add A Staff User
Add A Service or Feature
Subject
Case Origin
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Incoming Call
Email
Voicemail
Web
Training Session
Outgoing Call
Future Task
Walk-up
Chatter Answers
Web - Phone
Web - Email
Provider Type
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Prescriber
Therapist
Intern/Student
Service or Feature Requested
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Advanced Clinical Workflow Bundle
AI Notes Assist
API Request
Claim Assist
Clearinghouse
Credit Card Processing
e-Prescribing (DrFirst)
Integrated Outbound eFaxing
IOP/PHP
PDMP (Prescription Drug Monitoring Program)
RCM (Revenue Cycle Management)
Request A Replacement Token
Request More Information
Standalone Outbound & Inbound eFaxing
Telehealth
How Many Users To Add or Update
*Maximum 4 Users Per Request
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1
2
3
4
New Or Modify Package
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Sign Up For Service
Make Changes To Existing Service
Request Information
Plan
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AI Notes Assist- All Providers
AI Notes Assist- Choose Your Seat
AI Clinical Workflow Bundle- All Providers
AI Clinical Workflow Bundle- Choose Your Seat
Please provide us with the first and last name(s) of your prescriber(s) that need PDMP added.
PDMP Provider Names
Tax ID
Please use the Comment box to
inquire about your Valant
Subscription and provide your
preferred contact number in case we
need to reach out for further
information.
Information / Additional Comments
Requested Changes
A request to add this feature can only be submitted by a contract Signatory or Champion.
A request to modify your subscription can only be submitted by a champion or contract signatory.
Please Confirm You Are Authorized To
Request This Change
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I confirm I am the Signatory / Champion on the account and request this feature addition
Select Plan
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Practice-Wide Plan: $35 per month, per provider for all providers
Choose-Your-Seats Plan: $39 per month, per provider for select providers
List of Providers
You are
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Adding telehealth seats
Switching from Choose-Your-Seats to Practice-Wide Telehealth
Do you have a user with Admin Access?
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Yes
No
I’m not sure
Quantity of telehealth seats requested
Please specify the users that should have the ability to send faxes and login to the standalone application.
Please specify the users that should have the ability to create templates and packets.
Please Include Full Name and Email Addresses
To review all Valant Staff permissions, visit our help site article here:
Permissions for Staff
Please Provide us with the following pieces of information so that we can add your new user(s) to your account.
Clinical Administrator Information
You will need to identify a Clinical Administrator to complete your Dr. First setup. This person will have the ability to manage the EPCS Logical Access Control (LAC) and validate EPCS provider accounts. Typically, an administrative staff member would perform this function. If you do not have any administrative staff at your practice, you will need to identify a family member or friend over the age of 18 who is not a prescriber themselves. For additional questions, reference our Knowledge Base article
here.
Clinical Administrator for LAC
Clinical Administrator Email Address
Clinical Administrator Phone Number
Your Contact Information
After this form is submitted, a member of our Subscription Team will follow up with pricing information and next steps.
After this form is submitted, a member of our Merchant Services Team will follow up with pricing information and next steps.
Your Full Name
*
Your Email Address
*
Phone
*
Your Organization's Name
*
Your Organization's Valant ID
New User 1
Full Name
Email Address
Permission Level
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Front End Staff
Clinical Staff (No Billing Tasks)
Biller (No Clinical Tasks)
All Permissions
Copy Existing Staff User
DrFirst Clinical Staff
*Please Add User To Copy From In Comments.
Credentials
NPI
Tax ID
DEA
State Medical License Number
Add EPCS?
Postal Address EPCS Hard
Token Should Be Sent To
Add PDMP?
Add eRX
Comments
New User 2
Full Name
Email Address
Permission Level
--select an item--
Front End Staff
Clinical Staff (No Billing Tasks)
Biller (No Clinical Tasks)
All Permissions
Copy Existing Staff User
DrFirst Clinical Staff
*Please Add User To Copy From In Comments.
Credentials
NPI
Tax ID
DEA
State Medical License Number
Add EPCS?
Postal Address EPCS Hard
Token Should Be Sent To
Add PDMP?
Add eRX
Comments
New User 3
Full Name
Email Address
Permission Level
--select an item--
Front End Staff
Clinical Staff (No Billing Tasks)
Biller (No Clinical Tasks)
All Permissions
Copy Existing Staff User
DrFirst Clinical Staff
*Please Add User To Copy From In Comments.
Credentials
NPI
Tax ID
DEA
State Medical License Number
Add EPCS?
Postal Address EPCS Hard
Token Should Be Sent To
Add PDMP?
Add eRX
Comments
New User 4
Full Name
Email Address
Permission Level
--select an item--
Front End Staff
Clinical Staff (No Billing Tasks)
Biller (No Clinical Tasks)
All Permissions
Copy Existing Staff User
DrFirst Clinical Staff
*Please Add User To Copy From In Comments.
Credentials
NPI
Tax ID
DEA
State Medical License Number
Add EPCS?
Postal Address EPCS Hard
Token Should Be Sent To
Add PDMP?
Add eRX
Comments
Replace Hard Token
Replacement?
Attachments
Please attach any forms that have been submitted to the state for PDMP.
Please attach an example of your template request.
Attach up to 3 Files
Add File...
Acknowledgement
The cost to add this feature is 6 cents per page faxed. By submitting this form, you are agreeing to these charges. Valant will invoice you on a monthly basis based on your usage.
The cost to add this feature is $6 per fax line and $0.06 per page. Your billing will be usage based and you will be invoiced each month after we have analyzed your usage data.
The cost to add this feature is structured where the first signature request is free for all new patients (patients added after the first e-signature template is created - does not include imported patients). All other signature requests are $1 per signature request.
Your billing will be usage based and you will be invoiced each month after we have analyzed your usage data.
Telehealth subscriptions are billed monthly. The account will be billed for all telehealth licenses purchased, regardless of the number of licenses in use.
Cost Acknowledgement
Formstack Auto-Assign
Formstack Autoresponse
Case Type
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Add a Vendor Service
Adjustment
Billing
Cancellation
Clearinghouses
Documentation
DrFirst
Duplicate
E-Labs
Integrated Outbound eFaxing
Mobile Notes / Mobile Calendar
Other
Renewal
Spam
Subscription
Telehealth
Upsell
Valant Integrated Credit Card Processing