EmailMe Form - CollaborateMD Konnector Request

Name of KipuEMR Facility *

(This must be the full legal name as organized and registered with the state.)

Your KipuEMR Instance URL: *

Name of Customer in CollaborateMD (CMD): *

CollaborateMD (CMD) Customer Number: *

Konnector Name (Special characters are not supported like ; * ? ",) *

What naming convention do you want to give your Konnector?

For example, "CollaborateMD - Demo Detox"

CollaborateMD (CMD) Location/Facility Name: *

Please specify the location(s), you wish to associate with this Konnector.

CollaborateMD (CMD) Facility Sequence # *

CollaborateMD (CMD) Provider Name: *

CollaborateMD (CMD) Provider Sequence #: *

Location (If Applicable)

If there are multiple locations associated with Kipu, please provide the specific location(s) you would like to associate with this Konnector.

Program (Optional)

If you are utilizing Billing by Program, kindly indicate the program(s) you wish to associate with this Konnector.

Building (Optional)

If you are using Billing by Program, please provide the specific program(s) you would like to associate with this Konnector

Please feel free to provide us with any additional information or details you have regarding this request:

Please provide your contact information

Name *

First Last

Phone *

### - ### - ####

Email *