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Name of Practice
Email Address
Type of Physician
Street Address
City
State/Province
Zip/Postal Code
Country
Main Phone
Fax
Website (If Applies)
What type of services are you looking for?	Full Practice ManagementClaims OnlyTemporary Help
What is your current billing set up?	In-house BillingOutsourced but not happyNew Practice
How many providers are in your office?
What percentage of claims are Medicare?	NoneLess than 50%More than 50%
What percentage of claims are Public Aid/Medicaid?	NoneLess than 50%More than 50%
What percentage of claims are Blue Cross/Blue Shield?	NoneLess than 50%More than 50%
How would you like us to contact you?	EmailPhone
Contact Person's Name
How are you currently filing your claims?	PaperElectronically
How many claims are you filing a month?
What percentage of claims are being rejected?
What types of rejections are you seeing the most?
How much is the average amount you get paid from a visit?
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