How did you find us? (google, yahoo, msn, hotmail, etc.)

First Name

Last Name

Practice/Clinic Name

Your Role? (Owner/Partner, Ofc. Mgr, Consultant)

Address Line 1

City

State

Zip Code

Daytime Phone

Fax

E-mail Address

Medical specialty

New Practice or Existing?

Avg. daily # patients

Avg. Gross Monthly Charges $

Avg. $ Payments/Month?

Currently doing billing inhouse? (Y/N)

How many days/week do you process claims?
(daily, 3-4, 1-2, once, etc.)

If doing inhouse, how many full-time dedicated billers?

Primary reason for making a change?

What is your timeframe to make a change?

Are you interested in a billing cost analysis? (no charge - additional internal information will need to be provided)

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