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Start sending online orders and referrals now:

  • Fast, accurate orders and physician referrals to any provider in the network
  • Real-time status so you know when referrals are received, processed, and when appointments have been scheduled
  • Stay connected to other providers with two-way messaging and the ability to attach H&P and other documents

Please complete the enrollment form and your login credentials will be sent once your application has been processed.

Office/Practice Information


Practice Address*
Office/Practice Size*
To multi select Specialties from this list hold ctrl while clicking on each Specialty

Access & Notifications

Your office contact email will receive status notifications - use this field to designate additional recipients.

Office/Practice Users

Please enter information for staff members who will send and track orders and referrals.


Staff User 1*
Staff User 1 Permissions:*
Check all that apply.
Staff User 1 DOB*
Add Another Office User?*
Staff User 2*
Staff User 2 Permissions:*
Check all that apply
Staff User 2 DOB*
Add Another Office User?*
Staff User 3
Staff User 3 Permissions:*
Check all that apply
Staff User 3 DOB*
Add Another Office User?*
Staff User 4*
Staff User 4 Permissions:*
Check all that apply
Staff User 4 DOB*
Add Another Office User?*
Staff User 5*
Staff User 5 Permissions:
Check all that apply
Staff User 5 DOB*
Add another office user?
Staff User 6*
Staff User 6 Permissions:*
Check all that apply
Staff User 6 DOB*
Add another office user?*
Staff User 7*
Staff User 7 Permissions:*
Check all that apply
Staff User 7 DOB*
Add another office user?*
Staff User 8*
Staff User 8 Permissions:*
Check all that apply
Staff User 8 DOB*
Add another office user?*
Staff User 9*
Staff User 9 Permissions:*
Check all that apply
Staff User 9 DOB*
Add another office user?*
Staff User 10*
Staff User 10 Permissions:*
Check all that apply
Staff User 10 DOB*
If you have additional users, please submit another form for this practice.*

Your Providers

Please enter information for physicians who create orders.


In an electronic environment, the same legal weight associated with an original signature on a paper document can be associated with an electronic signature. Physicians are not required to be employees of the participating hospitals and thus agree to allow the use of his/her signature only for the purpose of ordering procedures at the hospitals and sending referrals to other medical providers.

- I certify that the identifiers assigned to me for the purpose of this attestation process will be kept confidential, will not be disclosed to others and will be used appropriately.


- I also understand that I am ultimately responsible for any orders transmitted using Order Facilitator on my behalf by my office staff.


- Furthermore, I understand that the privilege to use the Order Facilitator system may be revoked if it is not used appropriately.

Provider 1*
To multi select Specialties from this list hold ctrl while clicking on each Specialty
Provider 1 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 1 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another Provider?*
Provider 2*
To multi select Specialties from this list hold ctrl while clicking on each Specialty
Provider 2 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 2 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another Provider?*
Provider 3*
To multi select Specialties from this list hold ctrl while clicking on each Specialty
Provider 3 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 3 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another Provider?*
Provider 4*
To multi select Specialties from this list hold ctrl while clicking on each Specialty
Provider 4 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 4 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another Provider?*
Provider 5*
To multi select Specialties from this list hold ctrl while clicking on each Specialty
Provider 5 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Provider 5 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another Provider?*
Physician 6*
Physician 6 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 6 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?
Physician 7*
Physician 7 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 7 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?
Physician 8*
Physician 8 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 8 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?*
Physician 9*
Physician 9 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 9 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?*
Physician 10*
Physician 10 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 10 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?*
Physician 11*
Physician 11 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 11 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?*
Physician 12*
Physician 12 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 12 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?*
Physician 13*
Physician 13 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 13 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?*
Physician 14*
Use your mouse or finger to draw your signature above
Physician 14 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Physician 14 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
Add another physician?*
Physician 15*
Physician 15 signature type*
Please select method of providing provider's signature. Signatures must be received before your office can begin sending online orders.
Use your mouse or finger to draw your signature above
Physician 15 Signature File Upload*
No File Chosen
File uploads may not work on some mobile devices.
If you have additional providers, please submit another form for this practice.*

Scheduling.com (SCI Solutions) Services Agreement - For Physicians

Use your mouse or finger to draw your signature above
Do you agree with the terms of the preceding license agreement?*
Are you sure that you DO NOT accept the terms of the agreement?*
Name:*
Representative of your practice to contact if we have questions related to this request

Submit your information

Thank you for providing information on the New Practice Enrollment to Join our Order Facilitator Community for {$53107042 Physician Office/Practice Name}.

If your information is complete, please press the SUBMIT button below.  If you need to add additional users and/or providers, please use the PREVIOUS button below to make your changes.  *Please note if using the SAVE AND RESUME LATER feature on this form, only typed information will be saved.  Any signatures on the form will need to be resigned.

 

Thank you!  Please remember to click the SUBMIT button below when you're finished.

 

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Save and Resume Later
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