Select the Service Level best for you Basic$149Per Month Our “Basic Service Package” Includes: Up to 5 applications Client Setup Information Gathering Panel Selection Aid Application creation and submission Follow Up Notify client of application result Complete (or Maintain) CAQH Profile Premium$199Per Month Our “Premium Service Package” Includes: Unlimited applications per month Client Setup Information Gathering Panel Selection Aid Application creation and submission Follow Up Notify client of application result Complete (or Maintain) CAQH Profile Platinum$249Per Month Our “Platinum Service Package” Includes: UNLIMITED applications per month + MEDICAID and MEDICARE Applications Client Setup Information Gathering Determine which insurance panels you’d like to apply to Application creation and submission Follow Up Notify client of application result Complete (or Maintain) CAQH Profile Register Now and Get on More Insurance Panels Faster & Easier than Ever Before Step 1 of 2 50% Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Suffix ("Jr", "LCSW", etc.) Email* PhonePractice Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Create Username*for managing your InNet AccountPassword* Enter Password Confirm Password Strength indicator Number of Providers*Credentialing Service*Platinum Service Package ($249.00/month/provider)Premium Service Package ($199.00/month/provider)Basic Service Package ($149.00/month/provider)Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name Questions or Comments?Terms and ConditionsAgreement of Services Last Updated 3/1/16 Terms and Conditions By continuing, you are entering into a binding Agreement of Services (“Agreement”). This Agreement is entered into between InNet, LLC with its affiliates (“InNet”) and the Client (“Client”) and is intended to set forth the terms of service provided by InNet. Please read these Terms and Conditions (“Terms”) carefully. By signing up for InNet’s services, you are agreeing to these Terms. If you disagree with any part of the Terms, do not sign up as you will be strictly bound by these terms. In consideration of the mutual covenants set forth in this Agreement, the parties agree as follows: Description of Services InNet receives all required information and supporting documentation from Client. Using the information provided by the Client, InNet creates an internal profile, generates applications, and submits applications to requested insurance companies. InNet creates and provides protected access to a Client dashboard. InNet follows up with the insurance panels to determine application status. InNet will work with the Client to re-submit or appeal negative decisions made by insurance panels. Client Obligations Client will provide a valid payment option and keep account current. Client will provide required information and supporting documentation to InNet. Client agrees to sign and return applications. Scope of Work InNet will provide services on an “as-provided” basis. Services are deemed complete at the time of termination. InNet cannot guarantee Client acceptance onto insurance panels, as this decision is made by the respective insurance companies. Limitation of Liability The Client understands and agrees that InNet, and its affiliates, shall not be liable, under any circumstances or principles of law, for any direct, indirect, consequential, incidental, special, punitive or exemplary damages, including but not limited to damages for loss of business, use, data, profit, goodwill, or other intangible losses. Term and Payment This Agreement will be effective on the date that an account is created and paid, and shall remain in effect until the account has been cancelled or terminated. By starting services, Client authorizes InNet to automatically charge a monthly fee at the rate effective on the date services begin. The monthly subscription fee for the Services will be billed at the start of the subscription and each month (on the calendar day) thereafter until the account has been cancelled or terminated. Service is month-to-month. Payments are non-refundable. Client may cancel services as set forth below, and Client will continue to have access to the Provider Dashboard until the end of the billing period. Termination This agreement may be terminated by InNet by providing written notice to Client. The Client may cancel services by providing written notice to InNet. Upon termination, Client applications will be abandoned by InNet. If Client fails to provide payment, and any past due payment is not remedied within fifteen (15) days, the Client’s account will be suspended. Upon suspension, payment in full is required before additional services can be provided. If disputes arise between Parties, the Parties expect that such disputes will be resolved through open and honest discussion by representatives of the Parties. In the event that a dispute arises which cannot be resolved by mutual agreement, the resolution of any disputes arising under this Agreement shall be governed by the laws of the State of Utah, without regards to its conflicts of law provisions. Jurisdiction and venue for any action shall be only in Salt Lake County, Salt Lake City, Utah. Contact Us If you have any questions about these Terms, please contact us at email@example.com.Please indicate your acceptance:* I have read and agree to the Terms and Conditions. CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.