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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: