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Attorney/Lawyer Application

DocuBank® Application

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I am a member of the following DocuBank affiliate:

I plan to start implementing DocuBank in my firm:

In the next month or two
Sometime this year

The person in my office who will oversee enrolling my clients in DocuBank® (mailing enrollment forms, health care documents and payments) is:

I plan to use the following client card format:

Standard (free) see below
Logo card (one time fee)

Please PRINT exactly how would like your name and/or firm information to appear on your clients' DocuBank® Emergency Cards. You customize the text. (We will send you a proof of this for your approval.)

A "getting started" phone call is recommended so that you can take full advantage of all the benefits available to your firm with DocuBank.

Please schedule a telephone conference with me (approx. 10 min.)

I have a client maintenance plan (e.g. annual update):

Maybe soon

If you have any questions or comments, please enter them below.

I am electing to offer the DocuBank service to my clients. I understand that DocuBank stores my clients' legal healthcare documents and related information and is not responsible for verifying the accuracy or completeness of documents or information provided to DocuBank. I further understand that DocuBank: will contact my clients to pursue membership renewals unless I elect to pay the client renewal and do so in accordance with DocuBank policy; as part of the fax to physician marketing program DocuBank will send a memo to my client's doctor that appears to come from my office if I provide a fax number for my clients physician on the enrollment form; does not accept responsibility for the accuracy, completeness or updating of any client medical information provided to DocuBank; DocuBank will attempt to contact my clients to allow them to update their information annually. I agree to not distribute DocuBank intellectual property or use such property to establish a service similar to DocuBank for a period of two years from my last client enrollment in DocuBank.

(Typing your name here will be considered a valid signature and an assent to the paragraph directly above.)

DocuBank is a registered trademark of Advance Choice, Inc.