Client Server Termination Checklist Do note, CMMS requires at least 90 days' notice to cancel any service or invoicing. Also, there will a $250 fee to reactivate the ChartMaker® Health Portal for e-prescribing and other services, and a $250 fee to reactivate Waystar for electronic billing, ERAs, and Eligibility.Also note, if you have any contracts with STI Managed Services, please contact them directly at hwsupport@sticomputer.com or 610-575-2300.Please complete the following form when requesting termination of services. Practice Name*Practice Address* Street Address City State / Province / Region ZIP / Postal Code Practice Tax ID*Contact Name* First Last Contact Phone*Contact Email* Date you will no longer need access to Waystar for sending claims.*Please take into consideration the amount of time needed to submit claims and work outstanding receivables. Do note, there is a $250 fee to reactivate this service. MM slash DD slash YYYY Date you will no longer need access to the ChartMaker® Health Portal and Patient Portal.*Once deactivated you will no longer receive lab information or be able to electronically prescribe medications. In addition, your patients will no longer have access to the ChartMaker® Patient Portal. Do note, there is a $250 fee to reactivate this service. MM slash DD slash YYYY Date you will no longer need access to additional ancillary services, such as Patient Reminder Module, Patient Pay Online, Mobile App, Electronic Patient statements, and eFaxing (Updox).* MM slash DD slash YYYY If you are receiving labs in Clinical, or have an interface where data is shared, did you contact the vendor to deactivate? Yes No Select the vendor(s) and the vendor termination date.* Health Information Exchange (HIE) Interface Hospital Interface Lab Bridge Interface (Practice Manager) Lab Results Interface (Clinical) Instrumentation/Equipment Interface Image Enabled Results Delivery (IERD) Accountable Care Organizations (ACO) Interface Physicians Organizations (PO) Interface Health Management Platform Health Information Exchange (HIE) Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hospital Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lab Bridge Interface (Practice Manager) Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lab Results Interface (Clinical) Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Instrumentation/Equipment Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Image Enabled Results Delivery (IERD) Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Accountable Care Organizations (ACO) Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physicians Organizations (PO) Interface Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Health Management Platform Termination Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have a Dragon Medical One (DMO) account to terminate? Yes No To terminate your license, please have the Office Manager or Provider send an email to cm.support.team@azaleahhealth.com with the office name, address, and phone number stating the office is terminating the DMO license.The termination will be processed according to the terms outlined in your contract (e.g., if your contract ends on 1/1/27, Nuance will stop your contract from auto-renewing on 1/1/27).Nuance is no longer allowing offices out of their contract early and there are no exceptions. Following this, Azalea Health will send you a confirmation email once the cancellation has been officially acknowledged by Nuance.Method to reach you once office is changed or closed* Phone Email Reason for Termination*Additional CommentsPlease check to acknowledge:* By checking this checkbox, I acknowledge that CMMS is not Responsible to keep ChartMaker data backups of our Clinical and Financial data beyond 90 days once we cancel CMMS off-site backup services or ChartMaker® ASP/Cloud services. Please check to acknowledge:* By checking this checkbox, I acknowledge that Azalea Health offers several assisted export services as well as extended data access for the ChartMaker Medical Suite (Practice Manager/Clinical) application. It is important to make a decision prior to your office terminating your software contract. Information about Data Transition/Export options can be found here. Authorized SignatureDate MM slash DD slash YYYY *Information about Data Transition/Export options can be found here.
