Affordable Computer Systems

MEDGATEUSA

30 Iron Bark Ln

Aliso Viejo, CA 92656

Tel:  877-878-5668

 

Please sign this sheet and fax back to: 949-643-6738

 

Phone Support Sign-Up Sheet & Agreement

 Customer:

 

 Address:

 

 City, State, Zip:

 

 Phone:

 

 Fax:

 

 

 

 

 

 

 

 

 

Method of Payment

 

Type of Payment

Credit Card Number or Check Number

Expiration

 

VISA

 

 

 

MC

 

 

 

AMERICAN EXPRESS

 

 

 

CHECK PAYMENT

 

 

 

 

 

 

 

 

 

 

 

Support Plan Options

Mark the selected Plan

Support Plan

Minutes In Plan

Bonus Minutes

Total Minutes

Fees
Rate Per Minute

 

Silver

30

5

35

$75

 

 

Gold

60

10

70

$120

 

 

Platinum

120

20

140

$228

 

 

6 Month Limited

210

10

220

$357

 

 

1 Year Limited

460

20

480

$699

 

 

Per Minutes Charge

-

-

-

-

$19.99 Per Call

Plus $1.80 per minute

 

 

 

 

 

 

 

 

Rates effective July 1, 2004

 

Policy, Terms and Conditions:

Silver, Gold and Platinum plans can be used within 1 Year from invoice date.  Customers may upgrade to higher plan at anytime.  All plans are Non-Refundable and Non-Changeable after 24 hours and/or after usage of any minutes.  Selected plan must be paid in full by Check or Credit Card prior to usage.  Support Services are provided for your consultation, recommendations and helping you with issues and problem in regards to your patient accounting software only.  Issues and support incidents may be fixed or may not be fixed during support calls.  Customer agrees that he/she will pay for the time which tech-support representative will troubleshoot for finding results.  Support service department may recommend on site service.  On-site service fees are not included in any of the above support plans.  Fee for on-site service is invoiced separately and it is the customer’s responsibility.  MEDGATEUSA recommendation is to back up data before calling support representative.  MEDGATEUSA is not responsible for any data damage or data loss during, before or after any support calls.  Customers may dispute about the usage at the time of call.  No dispute will be accepted after support call.  Customers reserve the right to ask the support representative about total minutes used at the end of each support call.  By signing this support agreement sheet, I, the customer agree to all the terms and conditions of this support agreement.          

 

Total Charge On Credit Card or Check:                                     Customer Signature                                                

 

Date                            

 

Customer Name                                                                                                                                                          

 

Tech_Suport_SignupSheet  Rev-904