CONTACT INFORMATION

Full Name:

Practice Name:

Address:

Address: (Line 2)

City:

State:

Zip Code:

Email Address:

Phone Number:

PRACTICE INFORMATION

What is your practice specialty?
Allergy & ImmunologyAnesthesiologyCardiologyFamily PracticeGastroenterologyGeneral SurgeryHematology/OncologyInfectious DiseaseInternal MedicineNephrologyOphthalmologyOrhopedicsPain ManagementPediatricsPulmonary MedicineRadiologyRheumatologyUrologyOther
If other specialty, please provide specialty type

How many physicians are in your practice?

How many locations do you have?

Total number of staff performing billing and collections?

What practice management system are you currently using?

What EMR are you currently using?

Do you currently outsource your billing and collections?
---YesNo

FINANCIAL INFORMATION

Annual Charges

Annual Collections

Annual Claim Volume

OTHER INFORMATION

Where are you with regards to looking at outsourcing options:
Just started to exploreActively looking

Comments:

How did you hear about us?