DETAILED PROPOSAL FORM

Name of Client:

Account Executive name(s):

Name of Entity - Confirm:

Referral From Who/Where:

Change Healthcare Client:

YES

If Yes, do they use the ALS Dispatch Protocol:

YES

Image of the potential Client's ambulance for the cover page:

Image of the potential Client’s emblem/badge for the cover page:

Name(s) and title of individuals receiving the proposal for cover letter and cover page:

Address of Entity for Cover Letter:

County Name:

Phone Number:

Email address of your Contact (for UPS services):

The number of proposals requested:

Approximate Date of when the proposal is needed:

Proposals: Mailed directly to the potential Client or the account executive (or picked up)

Fee % - Recommended:

Additional equipment or software applications that need to be included in the fee and or Client Services Agreement:

Length of term for Client Services Agreement:

Reference on the Cover letter:

References in the body of the proposal:

Are any ePCR or equipment Charges included in the previous biller contract?

YES

Please attach a copy of the current biller contract.

Any Pass Through Charges?

Other Comments: