Practice Plan Upgrade - NEW

Name

First Name

Last Name

Lead Practitioner's Email Address:*

Number of practitioners are you registering*

If there are more than 15 practitioners, please contact us: hello@reimbursify.com

Choose your Plan:*

Practice Pro Annual Practice Pro Monthly Practice Plus Annual Practice Plus Monthly

Monthly signup requires a 3 month minimum. See all features at https://www.reimbursify.com/practice-upgrade.

Subscription Price* $

By choosing an annual plan, you save 10%! Your monthly cost is only:* $

Lead Practitioner's NPI number*

Billing Address

Address Line 1

City

State

ZIP Code

Credit Card*

Amount to be Charged Today:* $

Promo code

Your emailed receipt will reflect your discount

Amount to be Charged Today:*

Signup/Upgrade Agreement:*

I agree by pressing "Signup/Upgrade" below, my credit card will be billed the amount shown above on a recurring basis and my subscription will begin within 1 business day of signup. I will be credited for any remaining time on an existing Practice Plus plan if I am upgrading to Pro. Any monthly plan signups require a 3 month minimum subscription. Discounts will apply for 6 months (for monthly plan signups) or 12 months (for annual plan signups) after which subscriptions will renew at the regular rate. Any cancellation requests will be sent to practitioners@reimbursify.com at least fifteen (15) days prior to the next billing date. I understand that no refunds will be given for past charges.

Form Name*

Reimbursify Practice Upgrade