New Customer Account Setup

Please complete all required fields. Your information will be used to create your account in our billing system and to configure your QIKcap™ service agreement.

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All information is kept confidential and used solely for account setup and billing purposes.

* Required fields

Facility / Company Information

Facility / Company Name *

Facility Type *

NPI Number

National Provider Identifier (if applicable)

Billing Street Address *

City *

State *

ZIP Code *

Country

Shipping address is the same as billing address

Primary Contact (Accounts Payable)

First Name *

Last Name *

Title / Role *

Department

Email Address *

Phone *

Phone Extension

Mobile / Cell

AP / Billing Email (if different)

Where should invoices be sent?

Billing & Payment Preferences

Payment Terms *

Tax-Exempt Status

Tax Exempt Certificate # (if applicable)

Preferred Invoice Delivery

Email PDF AP Portal / EDI Mailed Hard Copy

AP Portal / EDI Vendor ID (if applicable)

Terms & Conditions & Signature

HAI Solutions, Inc. — Customer Account Terms & Conditions

Effective upon account activation. Please read carefully.

Account Establishment. By completing and submitting this form, the authorized representative of the above-named facility ("Customer") agrees to establish a commercial account with HAI Solutions, Inc. ("HAI Solutions") subject to credit approval. HAI Solutions reserves the right to decline account establishment at its sole discretion.
Payment Terms. Invoices are due and payable within the agreed payment terms stated above (Net 30 default). Past-due balances accrue interest at 1.5% per month (18% per annum) or the maximum rate permitted by law, whichever is less. Customer is responsible for all reasonable collection costs, including attorneys' fees.
QIKcap™ Subscription Service. The QIKcap™ System is provided under a subscription model billed monthly. Subscription pricing is based on staffed bed count or negotiated contract terms. HAI Solutions reserves the right to adjust pricing with 60 days' written notice.
Device Use & Regulatory Compliance. Customer agrees to use HAI Solutions products strictly in accordance with the Instructions for Use (IFU) and applicable federal, state, and local regulations. Unauthorized modification, reuse beyond labeled indications, or resale is strictly prohibited.
Shipping & Title. Risk of loss passes to Customer upon delivery. Shortages, shipping damage, or discrepancies must be reported to HAI Solutions within five (5) business days of receipt. HAI Solutions is not liable for delays caused by carriers or events beyond its reasonable control.
Limitation of Liability. HAI Solutions' total liability to Customer shall not exceed the total amounts paid in the three (3) months preceding the claim. HAI Solutions shall not be liable for indirect, consequential, incidental, or punitive damages.
Confidentiality. Customer agrees pricing, contract terms, and proprietary product data are confidential and may not be disclosed to third parties without prior written consent, except as required by law.
Data Use. Information provided will be used to create and manage the Customer's billing account in HAI Solutions' financial systems (QuickBooks Online) and CRM. HAI Solutions will not sell or share personally identifiable contact information with unaffiliated third parties.
Governing Law. This agreement is governed by the laws of the State of California. Any disputes shall be resolved in the state or federal courts located in San Diego County, California.
Entire Agreement. These Terms, together with any executed Order Form or Subscription Agreement, constitute the entire agreement and supersede all prior representations. Amendments must be in writing and signed by both parties.

I have read, understand, and agree to the HAI Solutions Terms & Conditions above. I confirm that I am authorized to enter into this agreement on behalf of the facility named in Section 1.

Authorized Signature *

Sign below using your mouse, trackpad, or finger (mobile).

Draw Signature Here

Printed Name *

Title / Role *

Date *

Email Confirmation *

A confirmation copy will be sent here.

Account Setup Submitted!

Thank you. HAI Solutions will review your information and follow up within 1–2 business days to confirm your account and QIKcap™ service start date.

Questions? Contact us at admin@hai-solutions.com

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Thank You! A member of our customer service team will reach out to you soon