Welcome to the AM-PAC Short Form License and Order Form!

This form collects all the information we need to grant you a license to the AM-PAC Short forms (all versions are included in the license).  As soon as you fill it out and submit, we'll set you up to download the AM-PAC Short Forms.  We'll also email you a copy of the contract (and keep a copy for ourselves) and invoice you within a week or two.

Thanks for ordering the AM-PAC Short Forms!


PAC-METRIX AM-PAC SHORT FORM LICENSE AND ORDER FORM


ORGANIZATION INFORMATION (the "Client")
CONTACT PERSON
BILLING ADDRESS
Invoices will be sent to the address below Attention: ACCOUNTS PAYABLE
SETTING
LICENSED FACILITIES

The AM-PAC Short Form is licensed on a Facility basis.  Enter the Name and Address of each Facility where the instrument will be used.

Enter the addresses of the facility(ies) below.  The number of address entries must match the number entered above.  If you only wish to license for Home Health practitioners, uncheck the "Hospital or Clinic" selection above.
LICENSED PRACTITIONERS
The AM-PAC is licensed by the number of practitioners who will be performing the assessments in patient homes.  Please enter the number of practitioners to license. 
ORDER TERM & PRICE
ORDER PAYMENT TERMS

PAC-Metrix Annual Subscription fee for AM-PAC Short Form Assessment

100% due ANNUALLY beginning the first day of the month following Order Form execution and upon the anniversary of the Order Form execution thereafter for the term of the Order.

GOVERNING TERMS AND CONDITIONS

1 This Order Form is subject to the terms of the Software License and Subscription Agreement attached hereto as Exhibit A (the “Agreement”).  By signing this Order Form the parties hereby agree and accept the terms of the agreement.

2 THE TERM OF THIS ORDER FORM IS ONE (1) YEAR OR TWO (2) YEARS AS DEFINED ABOVE AND SHALL AUTOMATICALLY BE RENEWED FOR SUCCESSIVE PERIODS OF ONE (1) YEAR UNLESS CLIENT OR MEDIWARE GIVES THE OTHER PARTY WRITTEN NOTICE OF NON-RENEWAL AT LEAST SIXTY (60) DAYS BEFORE EXPIRATION OF THE THEN CURRENT TERM OR UNLESS OTHERWISE TERMINATED AS PROVIDED HEREIN (OR AS PROVIDED IN THE AGREEMENT).

3 Annual fees for each 12 month renewal period shall be due and payable annually and in advance on the first day of the first month of the renewal period.  Annual renewal fee may be adjusted annually.

4 Pursuant to section 7.3 of the Agreement, upon termination of this order or any subsequent renewal of this order, all downloaded copies of the AM-PAC Short Form, whether in electronic media or print media, must be destroyed.  Copies which have been completed by patients may be retained, but may not be copied or reproduced for the purpose of conducting new assessments.

5 Client's Subscription Service Fee is based upon licensing the AM-PAC Short Form for use only at the address(es) entered above, or by the number of home health practitioners specified above.  Mediware retains the right to audit client usage.

6 This Order Form and Agreement are effective and valid when electronically signed by Client and accepted by an authorized Representative of Mediware.


Clicking the Submit button has the effect of signing a contract.  An email will be sent to the Contact Person's e-mail address with the information that was entered on this Order Form.  

Mediware will be in contact with you to deliver your AM-PAC Short Form access.  You will be invoiced for the cost of the licence.

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