PrivaPlan CD Order Form

 

Please print this form, complete and mail to address below:

 

The PrivaPlan HIPAA Compliance Solution is customized to reflect Connecticut laws.

                                                                  TO ORDER:
 
*Member Price(s) (CSMS, CSMS-IPA, CMIC, County Medical Associations)
  

- $325 per practice of 1-5 physicians
- $375 per practice of 6-10 physicians
- $425 per practice of 11 or more physicians
- $495 for allied health professionals
Shipping/Handling: $9.95 (Ground) or $14.95 (Overnight)

CD     $_________

S & H $ ________

Total:  $ _________
   
Company/Practice Name:

 
   
Name:

 
   
Address:

 
     (Street)                                   (City)                                (Zip)
       
Phone:

 

 Fax: 

 
 
Email:

 

 
Method of Payment:

- Check (mail with order form)   - AmEx     - Visa      - Mastercard     - Discover

Credit Card #: _______________________________ Expiration Date: ________

Signature: ________________________________________________________

 

Mail this Order Form to:
PrivaPlan Associates, Inc.
3 Monte Alto Way
Sante Fe, NM 87508

or fax at (505) 466-3942

To Order by Phone, call toll-free: 1 (877) 218-7707