| Medical Coding .Net Order Form (effective 11/20/2008) | Telephone: 888-288-2043 |
| SHIPPING ADDRESS | PO # (call for approval) | ||
| Name | Date | ||
| Company | Email address | ||
| Address (No PO Boxes) | |||
| City | State | ZIP | |
| Telephone | Fax | ||
| Where did you hear about
us? Current customer |
Web
Ad Print Ad |
Provistas / Dr. Carter's Corner
Web Search |
Association Referral: _______________________________ Other, specify: _____________________________________ |
| Credit card orders: ("Provistas" will appear on your billing statement.) Mail or fax to address below. | ||||||
| Name on Card | CC Number | Exp Date / | VISA | Discover | Amex | MasterCard |
| Billing Address | City | State | ZIP | |||
| ORDER INFORMATION |
| Item |
Product Name (subject to availability--check website for latest info) |
Unit Price | Quantity | Total |
| PROMOTIONAL CODE (IF AVAILABLE) | ||||
| Order total (prices are subject to change--check website for latest info) | ||||
| Book and Software Shipping | STANDARD $5.99 first, $0.99 ea addl; FREE over $99 PRIORITY MAIL $12 for the first item and $5 ea addl |
2ND DAY $30 for the first item and $15 ea addl OVERNIGHT $55 for the first item and $20 ea addl |
||
| Claim Form Shipping |
PRIORITY MAIL Included in the product price. You can still choose expedited shipping to the right. |
2ND DAY $30 single or partial ream; $55 double reams; $100 case OVERNIGHT $60 single or partial ream; $100 double ream; $175 case |
||
| SUBTOTAL |
You may receive more than one shipment to complete your
order. Non-expedited delivery can take 14 days from the date your order is received. |
|||
| Tax | Multiply subtotal (including shipping) by 0.08375 for New York State or by 0.06 for North Dakota | |||
| TOTAL | Make checks or money orders payable to "Provistas, Incorporated" | |||
| Send orders to: Provistas, Incorporated Medical Coding .Net Orders 411 N 4th Street, Suite 5 Bismarck, ND 58501 Or Fax 253-323-5256
Tax ID: 13-4182778 |
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