1 Billing
2 Questionnaire
3 Payment

Account Info

Please enter your first name.

Please enter your last name.

Please enter your email.

Please enter your company name.

Please enter your phone.

Billing Address

Please enter your street address.

Please enter your country.

Please enter your state.

Please enter your city.

Please enter your Zip / Postal code.

HIPAA Fax Questionnaire

Do you have an existing fax line that you would like to use? *

Yes, I have an existing fax line.

What is the fax number you intend to port over? (required) Porting numbers may take longer due to the process of obtaining and releasing authorized party information.

No, I would like a new fax line.

What would you like the area code to be on your new fax line? (required)

(required)

I will complete this information later

HIPAA Fax 100

HIPAA Fax

1 Fax Line 1 Portal User Up to 100 pages/month

Price (1*$9.95) /month

$10

Processing Fee (3%)

$0.30

Account Info

Billing Address

HIPAA Fax Questionnaire

Do you have an existing fax line that you would like to use? *

HIPAA Fax 100

Total:

$10.25