Webenabled

Registration Form

 
Practice Information
 
Practice Name
Customer ID (The number assigned as your HSPS account number)
HSPS Version
Contact Name
Address
 
City
State
Country
Zip
Phone
Fax
E-mail Address
 
eClaims
 
I choose to purchase eClaims.
 
eClaim Attachments
 
I choose to purchase Attachments.
 
QuickBill™
 
I choose to purchase QuickBill.
 
PowerPay™
 
I choose to purchase PowerPay.
 
eCentral Services™
 
I choose to purchase eCentral.
 
Customer Service Plan
 
I choose to purchase or renew an annual Customer Service Plan. (DENTRIX Only)
 
 
Payment Authorization
   
For Pre-Authorized Payments (You MUST choose an option)
Payment from Checking Account
Undersigned hereby agrees and authorizes Henry Schein, Inc. or its transfer agent to initiate entries to debit or credit the account at
the depository institution (bank) identified in the fields below. This authorization is to remain in full force until Henry
Schein, Inc. has received written notification requesting termination of service at least three (3) business days prior to any scheduled
payments.
Bank Name: Acct Name:
Acct #:   Routing #:  
Credit Card Payment
Undersigned hereby agrees and authorizes Henry Schein, Inc. to keep my signature on file and to charge the bankcard account
identified below for all amounts due on the Henry Schein account. This authorization is to remain in full force until Henry Schein,
Inc. has received written notification requesting termination of service at least three (3) business days prior to any scheduled payments. 
Visa MasterCard American Express American Express Discover Card
Acct #: Expiration:
Card Holder Name: Initials:  (type initials to confirm)

eService(s) Account *
Undersigned hereby agrees and authorizes Henry Schein, Inc. to charge my existing eService(s)/Dentrix account via my CC/ACH on file.
  (type initials to confirm)
* If you don't have a current payment option on file, you will not be registered until one is obtained.
 
Acceptance
 
 
I hereby select the Services and Payment Option(s) marked above and agree to the Terms and Conditions stated on this form for the service(s) I choose to purchase (click to view the terms and conditions). I have read this Agreement in its entirety and I understand and accept all of the provisions stated herein. By signing this agreement, I hereby authorize and approve the transmission by HSPS and Henry Schein, Inc. (and all affiliates, divisions, representatives and agents thereof) of all advertising and other faxes to the fax number(s) identified in this agreement for news and information regarding products, services and specials. This consent shall be valid until revoked in writing by an authorized representative of the licensee.  
 
 
Full Name:        (type initials to confirm)     DATE:

Sales representative who sent you to this form:
eServices go Live Date:

Notes:
I choose not to receive future faxed information.