THE CLAYTON GROUP, LLC. PRIVACY AND SECURITY TEMPLATES
ORDER FORM
After filling out the following form, print it and mail it, along with your payment, to The Clayton Group.
ORDER DATE
PO# (if applicable)
NAME (First Last)
TITLE
COMPANY
SHIPPING ADDRESS
CITY
STATE
ZIP CODE
PHONE
FAX
EMAIL ADDRESS
One copy of each edition you order, in Microsoft® Word format,
will be sent to the specified email address upon receipt of payment.
Please confirm that the email address you specify is correct.
Due to anticipated changes to ARRA, updates and revised templates
will be distributed via the N-Tegrity Solutions Group e-newsletter.
SALES REP (if applicable)
One license is required for each legal entity, including each group health plan, that will use the templates.
ITEM
QUANTITY
UNIT PRICE
TOTAL
ARRA TEMPLATE
$395.00
PRIVACY TEMPLATE
$695.00
Note: Effective October 1, 2009, ARRA Template must also be purchased. Select from the following Privacy Template editions:
Provider Edition
Health Plan Edition
Employer Group Health Plan
SECURITY TEMPLATE
$495.00
Note: Effective October 1, 2009, ARRA Template must also be purchased. Select from the following Security Template editions:
Standard Provider Edition
Small Provider Edition
COMBO PRICE: ARRA, PRIVACY, AND SECURITY TEMPLATES
$1,295.00
NEW: BUSINESS ASSOCIATE COMBO SET
$1,295.00
Make check payable to: The Clayton Group LLC
Subtotal
6% PA tax*
Grand Total
Mail Order and Payment to:
The Clayton Group LLC
Suite 100
53 Bethel Road
Glen Mills, PA 19342
