FREE Needs Analysis

What is todays date? *

Are your requesting a FREE Needs Analysis ? *

Yes No

Are your updating your medical practice billing needs. ? *

Yes No

Are you interested in learning more about EMR? We offer the best in the industry. (Electronic Medical Records) Will be mandatory for all practices in 5 years. *

Yes No

Is your practice just starting ? *

Yes No

How many providers are in your office? *

Would you be interested in seeing a DEMO of our EMR ?

Yes No

Title/Specialty: *

Do you need help getting your credentials with Medicare, Medicaid, BCBS *

Yes No

First Name *

Last Name: *

Organization or Practice name: *

Street Address:

Address (cont.): *

City: *

State, Zip/Postal Code: *

Country:

Work Phone: *

Cell Phone:

Fax:

E-mail: *

What type of services are you looking for?

HIPAA consulting *

Yes No

A/R Management and/or Cleanup Which includes electronic insurance billing. *

Yes No

Patient Reimbursement Solutions *

Yes No

Software Sales and Training on Our EMR or PM software *

Yes No

All of the above *

Yes No

What percentage of claims are Medicare? Above 50% or below 50% *

What percentage of claims are Blue Cross/Blue Shield? Above 50% or Below 50% *

How would you like us to contact you? Phone E-mail Fax Mail

Contact Name/Title

Best time to contact you?:

How are you filing claims now? *

How many claims are you filing per month? *

What is your average receivables per visit? *

Additional Comments: