Provider Services, Inc.

PSI-Lytec 2011 Order Form

Practice Name: ___________________        Phone (      ) _________________

Practice Type/Specialty: _____________        Fax (      ) ___________________

Contact Name: ____________________         Payment Method: Check# _______   

Address: _________________________        Circle One:  VISA    /Mastercard 

City, State, Zip: ____________________        Credit Card #: ________________

Previous Serial #: __________________         Exp. Date: ____________Code         

Order Date:______________________         Signature: ____________________

    Lytec 2011             New Price     from 2010   from 2009            Total Price

2011 Single-User         $3,361.00       $975.00      $2,857.00      $ _____________

2011 Multi-User           $4,259.00      $1,235.00     $3,620.00      $ _____________

2011 Professional       $4,820.00      $1,398.00     $4,016.00      $ _____________

2011 Client Server 5   $5,493.00      $1,593.00     $4,669.00      $ _____________

2011 Client Server 10 $7,176.00      $2,081.00     $6,099.00      $ _____________

2011 Client Server 20$12,449.00     $3,610.00   $11,046.00      $ _____________

Lytec CS 5 Add-on pack $ 2,688.00    $779.00     $2,285.00      $ _____________

We have your current version of Lytec as: ________________                             

Discount by Lytec

          Promo 20%          (Discount expire on 6/24/2011)       $ _____________

                                                            Lytec Software subtotal $ _____________

                                                            Special Discount by PSI    $ _____________

Lytec MD Prices

Lytec MD (Per Provider-Includes New Lytec 5 users)$6,300.00  $ ____________

          Lytec MD–Annual Maintenance(Required w/ MD)    $1,500.00  $ ____________

Additional Services:                                                         

Technical Support

          One Year Support (unlimited user)                        $999.00   $ _____________

          Hourly Support                                                         $90.00   $ _____________

                                                                                          Subtotal  $ _____________

All sales are final                                                 Sales Tax (7.3%)$ _____________

                                                                                              S & H   $ _____________

1-2 Hours of FREE Installation/Training with NEW Order        

                                                      TOTAL DUE        $ ____________________

Make Check Payable & Mail to:

Provider Services, Inc.,

25493 Kansas Ave, Tonganoxie, KS 66086    (913) 369-3886 or fax (913) 369-3887