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Quote Request Hospitals

Transcription Client Questionnaire for Hospitals

Please provide us with the following information so that we can offer you a customized quote for your transcription services.
Organization Name:
Physical Address:
City:
State, Zip:  ,   
Mailing Address:
City:
State, Zip:
  ,   
Primary Contact Name:
  
Primary Contact Position:
Phone number:
  
Fax number:
Email Address:
Desired Begin Date:
Transcription Volume
Worktype
In-House
% of Volume
Service
% of Volume
Minutes
Lines
Turnaround
Time
History & Physicals
Consultations
Operative Notes
Discharge Summary
Progress Notes
Radiology
Emergency Room
Pathology
Clinic Notes
 
Volumes listed above are based on:
  Daily
  Monthly 		  Weekly
  Annual
 
Please provide the same information as above for any other (specify each type)
report types currently dictated but not listed.

           
Please provide the same information as above for any other (specify each type)
report types that are not currently being dictated.
           
 
Transcription/Dictation Process
What dictation system do you use?
 
Build
Version
Service Pack
Who owns this dictation system? Hospital Service  
What transcription system do you use?
 
Build
Version
Service Pack
Word processing program used for transcription? MS Word WP51 WP/windows
Other?
Are both systems accessible via the Internet? Yes No  
If yes, how?
Will the transcription accept a bidirectional interface? Yes No  
If yes, which? HL-7 Serial  
Other:
Additional information/comments
Technical Contact Information
Please provide us with the contact information for the information systems representative knowledgeable with both the dictation and transcription systems.
Name:
Telephone:
Email Address:
       
Transcription Costs
If utilizing in-house transcriptionists (MTs), what is the internal cost per line?
If applicable, is the organization looking to totally outsource, and for MMHSI to acquire current in-house MTs? Yes No
If utilizing a service, what is the contracted billing method? Your system linecount
Gross lines
MTSO linecount
Other
Don't know
Additional Comments:

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