We Can Build a Great Looking Website for Your Business. Additional Services Available:

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1 WEB DESIGN SERVICES We Can Build a Great Looking Website for Your Business With over a decade of experience in the Healthcare Industry, HomeCare Provider Services offers a great opportunity to enhance your company image with a custom designed Web Site for your business. Our Web Design Program is a cost effective solution that provides you with complete access to modify and update your website as your business grows. Take a look at some of the features below and get started Today *Starting At $ *Includes Advanced Website Creation, Domain Name and Registration Not Included with this Program. Please review additonal services below. This Package includes (One) Year Hosting Service. Online Ordering Setup Not Included with this offer. Website Training Included. POWERED BY Additional Services Available: Domain Name Registration & Hosting Website Hosting Service *Online Ordering Platform Setup Charge $50.00 Annual Fee $ Invoiced Annual $ One Time Fee *Product Additions, Details and Pricing in not included in Online Ordering Platform

2 WEBSITE ASSESSMENT FORM COMPANY INFORMATION Company Name: Date: Primary Company Address: Primary City/State/Zip: Primary Company Phone Number: Primary Company Fax Number: Primary Business Owner: Primary Company Owner Primary Location Manager: Primary Location Manager Company Tag Line or Slogan: Primary Address for your Customers to Contact Company: Does your Company offer Consumer Financing: YES/ NO If YES whom: Provide State and National Associations your Company Belongs To: List any State or National Certifications: Provide any Buying Groups your Company is Associated with: Insurance Companies Accepted: HOURS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday *Additional Location 1 *Additional Location 2 *Additional Location 3 Address: Address: Address: City: City: City: State/Zip: State/Zip: State/Zip: Phone: Phone: Phone: Fax: Fax: Fax: Store Manager: Store Manager: Store Manager: *Please Attach Additional Locations if Needed WEBSITE INFORMATION Does your Business Own Website Domain Name: YES/ NO *Do you need to Register a Website Domain: YES/ NO Website Domain Name: Requested Domain Name: Where is your Website Domain Name Registered: (example GODADDY) Username for Website Register: Password for Website Register: *Do you want to offer Online Ordering Platform to Website? YES/ NO (Products must be loaded separately by company) *One Time Setup Charge $250 (requires additional information) for Online Ordering Platform *Website Registration Fee $50 Yearly *Website Hosting Fee Additional $100 Yearly

3 PRIMARY BRANDS & SUPPLIERS (click or add) OTHERS List Below Golden Pride Ez-Access Phillips ResMed Caire Invacare Harmar Medline Rose Pedifix Drive Merits Dr. Comfort Essential Standar Carex Responsive Nestle First Quality Pedifix Jobst Medlift Hollister ABOUT YOUR COMPANY EXAMPLE: Quality home medical equipment, caring and experience; that s what ABC Medical Equipment has been providing to our friends and neighbors in (region or market) since We provide top quality medical equipment and supplies from the most trusted manufacturers and combine it with superior customer service. Count on ABC Medical Equipment; we ll take good care you and your family for as long as you need us. DESCRIBE YOUR COMPANY:

4 SERVICES OFFERED EXAMPLE: Respiratory, Mobility, Delivery and Customer Service Specialists to Help You ABC Medical Equipment understands the importance of good customer service and a qualified, caring staff. When you need them, our respiratory professionals, mobility specialists, customer service representatives, delivery staff and billing associates are available to answer your questions and to get you what you need. Whether you are a new customer or an old friend of ours, you can count on great care from ABC Medical Equipment. Our expert staff takes the time to give each of our customers the personal attention he or she deserves and are trained to find the right products for each individual. Home visits can even be arranged if someone is unable to visit us. We participate with most major insurance plans, are a Medicare provider, and will coordinate insurance billing for covered items. ABC Medical Equipment services include; Delivery within a 100 Mile radius 24 hour, on-call emergency service Labor for warranty repair of defective equipment Ongoing product support Billing of Medicare and private insurances Reworking of denied insurance claims Cleaning of respiratory and medical equipment Loaner products while client's product is in for service DESCRIBE SERVICES YOUR COMPANY OFFERS:

5 Product Categories Offered (click top 10 or add to other) Aids to Daily Living Bariatric Products CPAP Walkers Wound Care Personal Care Diabetic Shoes Modular Ramps Portable Con. Hospital Beds Skin Protection Pain Management Footcare Products Portable Ramps Stationary Con. Orthopedic Products Specialty Seating Lift Chairs Ostomy Supplies Stairlifts Respiratory Back Bracing Wheelchairs Compression Bath Safety Vehicle Lifts Nebulizers Bracing Supplies Walk in Showers other Scooters Nursing Supplies Incontinence Sup. Canes Walk in Tubs other Power Chairs Scrubs Rollators Complex Rehab Nutritionals other History of Company Example: ABC Medical has been serving the (city or region) area since In these years we have created a team of people who can use their knowledge and expertise to work with you and your physician for all your home medical needs. We work with referral sources making a transition from a nursing facility as comfortable as possible - to helping select the correct pillow for a better night's rest. We are more than a medical equipment company as we cater to adding quality to life... No matter what stage of life you may be in. DESCRIBE THE HISTORY OF YOUR COMPANY: Mission Statement Example: The mission ABC Medical Equipment is to provide the highest quality of service to each patient and referral source. We believe our attention to detail and concern for each patient are pertinent requirements for our respiratory therapy, rehabilitation management, and durable medical equipment services continued futures. PROVIDE YOUR COMPANY MISSION STATEMENT: Additional Information Requested, Please submit this document and all Images and Company Logo s to: Angelo@HomeCareProviderServices.us