Onboarding Medical Form | WorkForceSync

Legal organization name *

DBA (if applicable)

Practice website *

Main contact name & title

Compliance or privacy contact (if different)

Contact email *

Contact Phone Number *

Check all that apply *

Appointment scheduling / rescheduling

Intake or pre-screening

nsurance verification

Reminder & follow-up calls

Billing or payment questions

Other:

Will PHI be involved? *

Yes

No

Not Sure

If yes, what type? (optional but helpful) *

Patient name / DOB

Appointment info

Symptoms or complaints

Insurance details

Medication or treatment info

Choose your comfort level *

Extra-Safe

Standard Healthcare

Custom Rules

Authorized signer name & title *

Signer email address *

Preferred contract / legal contact email *

Thank you for your feedback!