Sign Up

Please use one of our sign up options to get started. For those short on time, our “Quick Sign Up” form is designed to communicate your essential issues in a few words, allowing us to respond rapidly with a choice of post sign up solutions. The “Full Sign Up” option allows DATAppointment to immediately begin building a plan to accommodate the needs of your practice, even as soon as our first conference. DATAppointment is ready to become your virtual front office!

Quick Sign Up

Enter your name, practice name, email, and phone number below, and we’ll contact you to discuss how DATAppointment can help your practice.

Or, if you’re ready, click “Full Sign Up” above to fill out the full form.

Full Sign Up

Fill out the form below, click the button at the bottom to print the forms, then sign them and fax them to us at (310) 979-3283.

Practice Information
  Office Hours Doctor’s Hours / Available Scheduling Hours
Accepted Insurance Carriers
Payment Plans
Additional Comments
Letter of Intent

You have requested that DATAppointment provide patient ReCare related services for your office on the following basis:

  1. DATAppointment will provide a minimum of hours per week on patient ReCare related services.
  2. You will pay DATAppointment weekly for services rendered at the agreed rate of
    per hour, subject to cancellation at will by you or DATAppointment.
  3. DATAppointment will record all time incurred for your account, rounded to the nearest five minutes and will provide you a weekly time record with DATAppointment’s weekly bill which will be payable by credit card charge.
HIPAA Confidentiality Agreement

I understand that while performing my official duties I may have access to information that is classified as either confidential or sensitive or protected health information. Confidential information is information that identifies an individual or an employing unit. Sensitive information may be financial or operational information that requires the maintenance of its integrity and assurance of its accuracy and completeness. Protected Health Information (PHI) means individually identifiable health information that is transmitted or maintained in any form or medium. Confidential, sensitive, protected health information is not open to the public. Special precautions are necessary to protect this type of information from unauthorized access, use, modification, disclosure, or destruction.

I agree to protect the following types of information:

  • Client information (such as, disability insurance claimants, recipients of public social services, participants of state/federal programs, employers, etc.).
  • Information about how automated systems are accessed and operated.
  • Wage earner information.
  • Any other proprietary information.
  • All data elements described as protected health information in HIPAA (Section 164.514).
  • Operational information (instructional manuals).

I agree to protect confidential and sensitive and PHI by:

  • Accessing, using, or modifying confidential and/or sensitive and/or PHI only for the purpose of performing my official duties.
  • Never sharing passwords with anyone or storing passwords in a location accessible to unauthorized persons.
  • Never accessing or using confidential and/or sensitive and/or PHI out of curiosity, or for personal interest or advantage.
  • Never showing, discussing, or disclosing confidential and/or sensitive and/or PHI to or with anyone who does not have the legal authority or the “need to know”.
  • Storing confidential and/or sensitive information in a place physically secure from access by unauthorized persons.
  • Never removing confidential and/or sensitive and/or PHI from the work area without authorization.
  • Disposing confidential and/or sensitive and/or PHI by utilizing an approved method of destruction, which includes shredding, burning, or certified or witnessed destruction. Never disposing such information in the wastebaskets or recycle bins.


Unauthorized access, use, modification, disclosure, or destruction is strictly prohibited by state and federal laws. The penalties for unauthorized access, use, modification, disclosure, or destruction may include disciplinary action and/or criminal or civil action. DATAppointment reserves the right to monitor and record all network activity including e-mail, with or without notice, and therefore users should have no expectations of privacy in the use of these resources.