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Please fill up all information to request your instance to be built.
Please fill up the information to request your OptiSina instance build.
01Practice Information
Practice / Group Name ★
Group NPI Number ★
Primary Contact Person ★
Title / Role ★
Email Address ★
Phone Number ★
Street Address ★
City ★
State ★
ZIP Code ★
02Practice EMR / EHR System
EMR / EHR System ★
EMR Version / Platform
EMR Admin / IT Contact Name
EMR Admin Email
EMR Admin Phone
03Locations & Facilities Served
Please list up to 3 facilities below.
⚠️ Important Notice Regarding EMR Connectivity: Please be advised that EMR vendors may assess a third-party integration or connectivity fee per facility (for example, PointClickCare charges approximately $65 per facility). These fees are separate from OptiSina’s service charges and are the sole responsibility of the client. Our team will provide full transparency on applicable fees during the onboarding process.
Facility 1
Facility 1 Name
Facility 1 Type
SNFIRFLTACHHospitalOutpatient Clinic
Facility 1 EMR
Facility 1 Admin Name
Facility 1 Admin Contact (Email / Phone)
Facility 2
Facility 2 Name
Facility 2 Type
Facility 2 EMR
Facility 2 Admin Name
Facility 2 Admin Contact (Email / Phone)
Facility 3
Facility 3 Name
Facility 3 Type
Facility 3 EMR
Facility 3 Admin Name
Facility 3 Admin Contact (Email / Phone)
04Users & Roles
Please list up to 4 users who will need access to OptiSina.
User 1
Full Name
Email Address
Role(s)
Physician (MD/DO)Nurse PractitionerPhysician AssistantBilling/CodingAdmin/Support
Individual NPI (if MD/NPP)
User 2
User 3
User 4
05Commonly Used CPT Codes
Please check the CPT codes your practice uses most frequently.
Evaluation & Management (E&M)
99221-99223 Initial Hospital Care99231-99233 Subsequent Hospital Care99238-99239 Hospital Discharge99304-99310 Nursing Facility Care99324-99328 Domiciliary/Rest Home99334-99337 Home Care
Additional E&M CPT Codes
Consultations
99251-99255 Inpatient Consultation99241-99245 Office Consultation
Procedures & Injections
20610 Major Joint Injection62321-62323 Epidural Injection64483-64484 Facet Joint Injection64490-64495 Paravertebral Block97110 Therapeutic Exercise97140 Manual Therapy
Other Frequently Used CPT Codes
06Priorities & Timeline
Rank each feature — 1 = Highest Priority, 5 = Lowest Priority.
🎙️ Voice-to-text clinical documentation1 — Highest2345 — Lowest
📋 Smart clinical note templates1 — Highest2345 — Lowest
🔗 EMR integration and data sync1 — Highest2345 — Lowest
💰 Billing & coding optimization1 — Highest2345 — Lowest
📱 Mobile app access1 — Highest2345 — Lowest
Current Workflow Challenges
Additional Comments
07Agreement & Signature
I confirm that the information provided above is accurate and complete.I authorize OptiSina to contact facility administrators for integration purposes.I agree to participate in onboarding training sessions.
Print Name ★
Title ★
Date ★
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