EmailMeForm
CMD Add-On Services Request
This form is to be used by existing Kipu Billing Interface clients with CMD for the purpose of requesting Add-On services to your CMD account.
Important: If you have multiple CMD customers or would like more than one service to be enabled, please submit a new request form.
By submitting this form, you are requesting that Kipu enable the selected services in CMD, confirm you are authorized to make this request and acknowledge these features may incur additional fees.
If you experience any difficulties with this online 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
Data Copy
Data Snapshots
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!
