OneTouch EMR – Gold Plan AP - Lake Health Alliance, Inc.

OneTouch EMR - Gold Plan (Additional Provider)

OneTouch EMR Gold Plan, offered by Lake Health Alliance, Inc. offers everything in the Silver plan PLUS adds the Practice Management and Billing Software (no eClaims). Ideal for all-cash practices, or those who will send claims manually.

Please complete the following Questionnaire so we may set up your account properly.

Thank you for signing up for the OneTouch EMR Gold Plan offered through Lake Health Alliance, Inc. In order to get you set up properly, please take a moment to complete the information needed below.

EXISTING CLIENT INFORMATION FORM

[uacf7-row][uacf7-col col:6] Name of Practice: (Required)
[/uacf7-col][uacf7-col col:6] Please provide your account name (i.e. abcmedical1234) (Required)
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] First Name:
[/uacf7-col][uacf7-col col:6] Last Name:
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:4] Your Title: (Required)
[/uacf7-col][uacf7-col col:4] Your Phone #: (Required)
[/uacf7-col][uacf7-col col:4] Your Email: (Required)
[/uacf7-col][/uacf7-row]

You must have at least 1 provider in order to purchase this plan.

PROVIDER INFORMATION

[uacf7-row][uacf7-col col:4] Title of provider (select from drop down): (Required)
[/uacf7-col][uacf7-col col:4] First Name of Provider (if different from above): (Required)
[/uacf7-col][uacf7-col col:4] Last Name of Provider (if different from above): (Required)
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:4] NPI#: (Required)
[/uacf7-col][uacf7-col col:4] License#: (Required)
[/uacf7-col][uacf7-col col:4] State: (Required)
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] DEA#: (Optional)
[/uacf7-col][uacf7-col col:6] NADEAN #: (Optional)
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] Provider's Cell Phone: (Required)
[/uacf7-col][uacf7-col col:6] Provider's email address: (Required)
[/uacf7-col][/uacf7-row]

The Provider's information will be submitted to OneTouch EMR. They will contact the provider directly to collect additional information.

If there are any additional details or information you'd like to share, please include them below. (optional)

I accept the Privacy Policy

Once you Submit this information, you will be directed to the order page.

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