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Onelife Exam is offering a great opportunity to every individual who are currently active in their
career as a healthcare provider and have business with us, enjoy the benefit of our service, and at
the same time, earn additional referral incentive bonus through our referral program while providing
good service to your client.
We fully guarantee your satisfaction and expectation to the highest level of service we can offer.
We are committed in providing our client a cost effective solution, flexible and dependable service
while maintaining an efficient reimbursement, quick and accurate payment collection based on our
soft collection method, accomplished through our aggressive and consistent approach, accurate
billing collection, to achieve maximum reimbursement.
We value your business the same way we value our business. You can depend on us, be on top, we
can help each other in achieving our common goals and objective to become a global leader in
providing excellence service to our client.
Our clients benefited from our enhanced knowledge, expertise and commendable performance in
obtaining medical billing services through our operational and strategic practice management.
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Please read and check off the following for registration
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I understand that upon completing this registration form, I am fully aware that I agree to respect and abide
by the conditions of Onelife Exam and all Federal, State and local laws pertaining to the confidentiality of
identifiable medical, personal and any confidential information obtained from their website.
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I understand that by signing-up on the registration form, all information entered herein will be used to
disclose information to authorized Onelife Exam personnel to process and complete any work order or
on-line order upon my request.
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I also agree and authorized Onelife Exam to use my personal information to advertise and promote my
nature of business but, limited to represent me in any business contract or business transaction in my
behalf.
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I understand that all medical or any health information I have provided for my clients are confidential and I
have the authority to disclosed this information to Onelife Exam to process their medical insurance claim.
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I understand that upon registration and submitting my information, Onelife Exam has the right to verify and
check the information I have provided, they also have the right to approved and disapprove my application
to obtain a Login ID or password to access their website and secured site. I also understand that upon
typing my name on the space provided for my electronic signature, this will serve as the equivalent of my
legal signature. By clicking the submit button, I will be accountable for all representations made at Log In
and for all work done under my Log In ID.
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I understand that this is not a contract or a binding agreement,but solely, for registration
purposes only. My account will be renewable every year and may be subjected for cancellation
by the discretion of Onelife Exam. And by checking the box, I agree with this terms and
conditions.
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Provider's Name
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Business Address
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Apt/Ste
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City/ State
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Zip Code
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Fax Number
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Cell phone
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Birth Date/mm/day/yr
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UPIN
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Group ID #
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Yr in Business
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Email Address
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Type of Practice
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Office Phone
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Ext. No.
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Medical Group/Organization
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Business Name
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Yes
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No
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How many staff do you have?
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Do you have your own medical billing staff?
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1-2
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3-5
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1-50
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How many clients do you have in a month ?
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100-200
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300-500
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600 or more
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What method do you currently use to process your insurance claim ?
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Paper Claim
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Electronic Claim
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How many insurance claims does your office process each day ?
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1-5
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6-15
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16-25
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26-or more
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$300 or more
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$45
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Approximately, what is the average dollar amount of each claim ?
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$70
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$120
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$200
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Have you ever been contracted with a billing service?
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Yes
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No
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Yes
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If, your answer is no; are you willing to know more about the service we can offer?
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No
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Yes
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No
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Can we contact you ?
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EVE
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Anytime
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AM
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PM
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When is the best time to contact you ?
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Date Signed/Registered
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Provider's Electronic Signature
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