458318 Physicians Account Creation Page

Physicians Create an Account Page. This effort will be one page in an already existing site that is based on a joomla platform with virtuemart as a shoping cart. (( intro text )) product will become available April 2011. If you wish to get on a priority list, please fill out the necessary information to set up an account. You do not have to place an order at this time in order to set up an account. Once an account is set up, you will be automatically listed in our Physician Locator Directory. ------------------------------------------------------- (( this will be a form for the physician to fill out the required info )) ((this account can be in joomla or virtue mart or something new. Please let me know of any suggestions if you have them )) Username Password Verify password Physician Name Practice Name Address City, State, Zip Code Practice Phone Number Contact Phone Number Email Physician License # Medical Device License# Medicare Certification for Medical Device # ------------------------------------------------------- Hospital Affiliate Name Address City, State, Zip Phone Number Name Address City, State, Zip Phone Number ------------------------------------------------------- Do you know of any practitioner/clinic who may be interested in this device? Name Contact Information Name Contact Information Name Contact Information ------------------------------------------------------- Within your practice, what is the potential use of this device? (( this should be a pull down list )) 1-5 per month 5-10 per month 10-20 per month 20-40 per month 50 or more per month ------------------------------------------------------- Will you need assistance with medical coding and billing for this device? (( this should be a pull down list )) Yes No A representative will be contacting you to confirm your account information and answer any questions you may have. When is the best time to contact you? ((this should be a text box)) Please retain the username and password that you choose. It is important that you keep this information for future inquiries or orders, and to inquire about existing orders. ------------------------------------------------------- To get on our priority list, a small deposit is required. Would you like to get on our priority list? (( this should be a pull down list )) Yes No ------------------------------------------------------- ((Submit Form button)) (( if they choose yes to provide a deposit for priority list placement, continue to next step. If they choose no, redirect to an information page that says: Thank you for inquiring about our product. A representative will be in touch with you to help answer any questions that you may have. ------------------------------------------------------- ((when the submit form button is clicked, the user should be directed to the shopping cart item for the product)) ((the following is information that should be on the product page)) ((the user should be able to choose the number of units that they would like to reserve. This product can only be reserved in multiples of 4 & 10)) (( this should be a pull down menu with the choices being only multiples of 4 & 10. We should only go up to 50 )) ((note)) This device contains live cells and has a shelf life of 3-5 days. A representative will contact you prior to availability, to correlate delivery with patient application. Physicians cost is $1,100.00 per unit. A Deposit of $100.00 per unit is required for priority placement on the reservation list. Balance due upon availability prior to delivery ((note)) This device is covered by most insurances including Medicare and Medicaid, and is reimbursed at $1,100. ------------------------------------------------------- (( general notes to developer )) This will be one of several account types on this site. It is important that we can distinguish between the different account types. An example of the reasoning behind this is the future physician locator. When this page is created it will need to search the database for physicians. We will not want any patients to be returned in any of the searches for physicians. There will most likely be additional account types in the future. Please keep this in mind while designing so as to accommodate future account types and the ability to distinguish the difference between users of different account types. When an account is created and when an order is placed, the email notifications should go to "orders email address". A copy of the notification also needs to be forwarded to the email address of the state representative that matches the state on the form that is being submitted. Currently there are only 2 state reps. One for SC and one for TX. I have them set up as contacts in joomla. As new contacts are added the forms should recognize this and copy them with the orders for their state. Example: if a doctor fills out a form and provides an address that is in the state of Texas, then the order should be sent to orders email address, then it should look in the contacts for the Texas state rep and send them a copy of the order. If there is not a rep in the contacts for that state then there will be no one copied and the only notification will go to orders email address. When a physician account is added, we need to keep the physician locator page in mind. The physician locator will basically just be a search directory were users can find a physician near them. I think as long as a data base is being maintained with the information that physicians are submitting then we should have what we need when it comes time to create the physician locator page. Please let me know if there is anything that you can think of that may need to be considered at this time in order to plan for this. Please do not include the physician locator page in this bid.