EmailMeForm
CMD Add-On Services Request
This form is for existing Kipu Billing Interface clients with CollaborateMD (CMD) to request Add-On services for your CMD account. To submit this request, you must be an active CollaborateMD Admin.
Important: If you have multiple CMD customers or wish to enable more than one service, please submit a new form for each request.
By submitting this form, you are requesting that Kipu enable the selected services in CMD, confirming you are authorized to make this request, and acknowledging that additional fees may apply.
If you experience any difficulties with this form, please contact Kipu Billing Support at IBSupport@Kipu.Health.
Please start by giving us some basic information about your facility.
Red Asterisks mean this information is required in order to submit.
Name of Facility
*
What is the URL of your KipuEMR Instance?
Please enter the website that you/staff visits to log into KipuEMR
Name of Customer in CMD
*
CMD Customer Number
*
Please check the CMD add-on service you are requesting to be enabled.
*
Address Verification - USPS Address Checking
Appointment Reminders
Automated Statements (Electronic Statements - Email and Text)
Automated Statements (Electronic Statements - Email Only)
Automated Statements (Paper Statements)
Claim Scrubbing
Claim Scrubbing Custom Edits & Analytics
Data Copy
Data Snapshots
Data Sync
Document Imaging
Eligibility
Enhanced User Printed Statements
ePS Claim Attachments**
In-app Credit Card Processing AND Patient Payment Portal*
In-app Credit Card Processing ONLY
Manual Electronic Statements ONLY*
Manual ERA Uploads
Patient Estimates & Eligibility
Patient Payment Portal ONLY*
WebAPI & Web Reporting
*Requires In-App Credit Card processing and the Patient Payment Portal
** Requires Document Imaging
Please provide us with any additional information you have about this request:
Please provide your contact information.
Please provide your name:
*
First
Last
Please provide your email:
*
Please provide your best contact phone number:
*
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We will confirm the completion of your request within 24 -48 hours.
Otherwise, if we have any questions we will contact you as soon as possible using the contact information in this form.
Thank you for being a valued client of Kipu Health!
