(1). The legal name of the entity responsible for executing the Agreement: (2). The full name of the facility or facilities where scribe services are to be provided: (3). The full name of the individual responsible for executing the Agreement: (4). The total amount of physician/ML (if any) coverage per day (if coverage varies by day, please specify): (5). The name and contact information of the individual with whom we would negotiate the Agreement: (6). The name and contact information for any hospital or group compliance representative with whom we should be in contact: (7). The type of documentation system currently in use and the details of any future plans to change same:
