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I agree to the Terms specified in the End User Agreement.
E-Signature
Disclosure:
By typing your name and clicking the "Submit" button, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. By clicking "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Document. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Company, or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You further agree that your signature (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Telehealth Clinical Evals. You are also confirming that you are the individual authorized to enter into this Agreement.
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Registration Type:
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Telehealth Eval Registration
ACES ATP Subscription
Do you have an account number?:
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Yes
No
Account Number:
User Type:
ATP
Admin
First Name:
Last Name:
Credential:
Email:
Phone:
(
)
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RESNA #:
Associated ATP(s):
Service Area:
Provider Name:
Provider Address:
Street:
City:
State:
-
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
N Mariana Islands
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Quebec
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Clinician Requested:
Any
Specific
Clinician Name:
Note:
Do you want to register for the ATP Evaluation and Home Assessment?:
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Yes
No
Subscription Type:
-
Individual Rate-199.00
Small Group,No.of ATPs:5-189.00
Medium Group,No.of ATPs:10-179.00
Large Group,No.of ATPs:25-169.00
National Group,No.of ATPs:50-159.00
National Group,No.of ATPs:100-149.00
Individual Rate-199.00
# of ATP Subscriptions:
# of Subscriptions (all subscriptions are a 1 year contract):
$199.00 per month per subscription
Card Issuer (Type):
-
Visa
MasterCard
AmericanExpress
Discover
Card Number:
(1111222233334444)
Card Expiration:
Month
01
02
03
04
05
06
07
08
09
10
11
12
/
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
Card Security Code (CVV):
First
Name on Card:
Last
Name on Card:
Street:
City:
State:
-
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
N Mariana Islands
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Quebec
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Phone:
(
)
-
Total Amount:
SaaS Agreement Fields
PAGE 1:
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Effective Date:
Client:
Principal Place of Business:
EIN:
Initials:
PAGE 2:
View
Disclosure:
By typing your name and clicking the "Submit" button, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. By clicking "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Document. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Company, or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You further agree that your signature (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Demo. You are also confirming that you are the individual authorized to enter into this Agreement.
Sign By:
Name:
Its:
Initials:
PAGE 3:
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Initials:
PAGE 4:
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Initials:
PAGE 5:
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Initials:
PAGE 6:
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Agreed and Accepted By:
Disclosure:
By typing your name and clicking the "Submit" button, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. By clicking "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Document. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Company, or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You further agree that your signature (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Demo. You are also confirming that you are the individual authorized to enter into this Agreement.
Signature and Title:
PAGE 7:
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Initials:
PAGE 8:
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Initials:
PAGE 9:
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Initials:
PAGE 10:
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Initials:
PAGE 11:
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Initials:
PAGE 12:
View
Initials:
PAGE 13:
View
Initials:
PAGE 14:
View
Effective Date:
Client:
Principal Place of Business:
EIN:
PAGE 15:
View
Disclosure:
By typing your name and clicking the "Submit" button, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. By clicking "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Document. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Company, or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You further agree that your signature (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Demo. You are also confirming that you are the individual authorized to enter into this Agreement.
Sign By:
Name:
Its:
Enter Result:
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Therapist Registration
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First Name:
Last Name:
Credential:
Address:
City:
State:
-
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
N Mariana Islands
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Quebec
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Phone:
(
)
-
Email:
License #:
Referring ATP(s):
The individual at the equipment provider who is completing the evaluation with you
Enter Result
4 + 9 =
ACES ATP, 9505 Hillwood Drive Ste 100, Las Vegas, NV, 89134
216.73.216.68
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CyberMight
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ATM Holdings
LLC®
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ATLAS