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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?

What is your current billing set up?

How many providers are in your office?

What percentage of claims are Medicare?

What percentage of claims are Public Aid/Medicaid?

What percentage of claims are Blue Cross/Blue Shield?

How would you like us to contact you?

Contact Person's Name

How are you currently filing your claims?

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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