Please note, the accuracy of your quote is based on the statistical information below.   Provide as
much detail as possible to receive the best quote.  We appreciate your interest in Alliance.
Type of Facility
Hospital
Clinic/Surgical Center
Private Practice
Other
Department
HIM/Med Rec
Imaging
Pathology
CV Lab
Other
What equipment would the service provide?
Dictation System
Ancillary Equipment
Text
If we will provide the dictation system, what is your preferred method of recording?
Landline/Cell Phone
Desktop Unit
Portable device
"Hands-Free" (Pathology)
Number of dictating
physicians?
Number of beds (hospital)?
Full-time
Overflow
Full-time or overflow coverage?
Average lines or minutes per month?
Yes
No
What Days?
Do you require 24/7 transcription?
Additional applications/platforms; i.e.,
HL7  interface, e-sig, auto-faxing.  If
an interface is requested, please
include the software platform your
facility is currently utilizing.
Your name and title
Phone number
Fax No.
Email address
Facility
Address
City, state and zip code
NOTE:  HL7 interfaces and/or PACS integrations require additional information and will not be included in        
web quotes.
877-AL MT INC (1-877-256-8462)
Local 281-589-7678
Fax:  281-550-4955
www.alliancemt.com
QUOTE
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