BAA: PRICING DISCLOSURE + Amniotic Membrane Portal BAA + Registration (#34)

First Name

Last Name

I agree to maintain the confidentiality of the Business Associate Agreement (BAA). I understand that by proceeding, I will have access to review the full BAA document.

yes, I agree to maintain confidentiality

Steps to Complete Your BAA:

Review: Scroll through the agreement below to review the full terms.
Download: Click the download link if you wish to save or complete the form offline.
Sign & Upload: Complete and sign the BAA, then return to this form and upload your signed copy in the field provided below.
Confirm: Check the box confirming you have reviewed and uploaded your signed BAA, then click Submit.

Business Associate Agreement (BAA) Completion Form: Amniotic membrane portal.

This form is intended for healthcare providers, facilities, and other covered entities that wish to engage in a business relationship with Total Surgical. Before proceeding, you will be asked to review and electronically acknowledge our Business Associate Agreement (BAA), which outlines our mutual responsibilities under HIPAA and applicable privacy regulations.

📄 Download the BAA here , complete it, and then upload your signed copy below.

Upload your completed Registration & Business Agreement

Confirmation of Uploaded Registration & BAA

I confirm I have uploaded the completed Registration Form and BAA.

BAA Amniotic Membrane Portal

BAA: Amniotic Membrane Portal Business Agreement Form No Registration

First Name

Last Name

Business Associate Agreement (BAA) Completion Form: Amniotic membrane portal.

This form is intended for healthcare providers, facilities, and other covered entities that wish to engage in a business relationship with Total Surgical. Before proceeding, you will be asked to review and electronically acknowledge our Business Associate Agreement (BAA), which outlines our mutual responsibilities under HIPAA and applicable privacy regulations.

📄 Click here to review the updated Business Associate Agreement (BAA)

You will then be asked to provide basic information and electronically sign the agreement. Upon submission, a copy will be emailed to you for your records, and you will be redirected to the next required form.

I have reviewed the Business Associate Agreement (BAA) and by checking this box, I acknowledge and agree to the terms of the BAA as my legally binding electronic signature.

I agree

Access Gate — NPI/Agreemen

NPI Verification Practice/Clinic Registration Form (#14)

First Name

Last Name

Primary Telephone

Primary Telephone is a:

Cellular Telephone

Landline Telephone

Preferred Contact Method, may select more than one

Cellular Call

Cellular Text

Landline Telephone

Email

Cellular Telephone

Landline Telephone

Email

Your Title / Role in the business

Practice/Company Name

Primary Address

Primary Address Line 1

Primary Address Line 2

Primary City

Primary State

Primary Zip Code

Country

Do You Need to add additional addresses?

yes

no

Addresses

Address 1	Address 2	City	State	Zip Code

You must input NPI or an Access Code Entry to see provider privileged information - ROI's etc.

Why required? To verify licensed provider status and unlock provider-only financial pages (pricing, reimbursement, ROI).
No NPI? Enter the access code we issued to authorized practice admins. This safeguard helps us protect proprietary and payer-sensitive information, comply with partner distribution policies, and ensure materials are viewed only by qualified professionals. Your NPI/access code is used solely for verification and audit purposes and is never used for billing.

Next Step:

Yes, see financials (NPI required)

No, I am not ready to provide NPI, I would like a consultation first

NPI #

Access Code (provided by KOSMD Consulting, Inc.

Confidentiality & Pricing Disclaimer Amniotic membranes

By proceeding, I confirm that I am a licensed provider or an authorized representative of a healthcare organization. I agree to maintain the confidentiality of all pricing, reimbursement, and financial information provided by KOSMD Consulting, Inc. This information is proprietary, presented on behalf of KOSMD Consulting’s partner companies, and is intended solely for internal professional use.

Pricing information is for reference only and is subject to change at any time without notice. KOSMD Consulting, Inc. and its affiliates make no guarantees regarding pricing accuracy, payer coverage, or reimbursement. Final pricing will always be confirmed at the time of transaction.

I understand that KOSMD Consulting, Inc. is not liable for any claims, reimbursement outcomes, or decisions made based on the financial data provided.

Terms & Conditions to View Financials of Amniotic Membranes via Portal

I agree to term & conditions

Would you like to share any questions?

Kimberley O'Sullivan, M.D., F.A.C.S.

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Contact KOSMD Consulting, Inc.

You must input NPI or an Access Code Entry to see provider privileged information - ROI's etc.