One-Time Summary Order

1

Which type of summary would you like?* This field is required.Choose Narrative for an overview. Chronological for a timeline, or Hybrid for both with the Reference Pack Included. Upload up to 5,000 pages per order. Your detailed order total will be shown after you finish all selections — no surprises. .

Chronological (+$400)

Narrative (+$500)

Hybrid Summary (+$1150)

2

Would you like to include a Reference Pack (+$250)?* This field is required.Includes both a Provider History and Medication History - a helpful supplement to your summary. Your detailed order total will be shown after you finish all selections — no surprises.

YESNO

3

How quickly would you like to get your summary?* This field is required.Every summary is delivered securely, as early as 5 business days from today based on availability. Your summary will be delivered on or before the date and time selected. Subscribers enjoy priority access. Your detailed order total will be shown after you finish all selections — no surprises.

4

Order Summary

Summary
{choicesummary}

$ {SummaryPrice}

Reference Pack
{choicerefpack82}

$ {RefPackPrice}

Delivery Date
{datelabel}

Total $ {orderTotal}

Next: Enter your name and email, then you’ll review and sign the required Business Associate Agreement (BAA) and agree to our Terms & Conditions before securely uploading your records and submitting payment. You’ll have one final chance to review everything before submission.

5

What's your name?* This field is required.Enter your first and last name for the order.

First Name

Last Name

6

Where should we send your completed summary?* This field is required.We'll deliver your completed summary here.

contact@yourcompany.com

7

YOURMEDREVIEW LLC – TERMS & CONDITIONS* This field is required.Please review the Terms & Conditions below and confirm your agreement before proceeding.

8

YOURMEDREVIEW LLC – BUSINESS ASSOCIATE AGREEMENT (BAA)* This field is required.Please review the Business Associate Agreement (BAA) below. Scroll to the end to confirm that you’ve reviewed it. You’ll sign electronically on the next page.

9

Sign to Confirm Agreement* This field is required.By signing below, I confirm that I have reviewed and agree to the YourMedReview LLC Terms & Conditions and the Business Associate Agreement (BAA) presented on the preceding pages. I understand that my electronic signature below constitutes a binding agreement under the Electronic Signatures in Global and National Commerce Act (E-SIGN) and applicable state law.

Clear

10

Ready to upload your record?* This field is required.Upload PDF file (up to 5,000 pages). Only PDF is accepted. If your file is larger, please compress it into a single PDF under 1 GB. Your file is encrypted and handled with full HIPAA compliance.

Drag and drop files here

Select files to upload

Max. file size: 1.0GB

PDF only · up to 5,000 pages · 1 file · up to 1 GB

11

ChoiceSummary

12

Summary Price

13

ChoiceRefPack

14

RefPackPrice

15

DateLabel

16

Order Total

17

My OrderPayment for your medical record summary. Securely processed via Stripe.

Description

USD

+ OR enter a custom value

First Name

Last Name