Please provide us with the necessary information...

 Please provide the following contact information:
 Fields in BOLD are required.

Name
Title
Practice Name/Group Name
Practice Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
E-mail

 Are you currently paying a full/part-time person wages plus benefits for your billing needs?

Yes   No

 Do you process your primary claims manually or electronically?

Manual   Electronic

 What percentage of unpaid claims are billing errors?

Select one Less than 5% 5% 10% 15% 20% More than 20%

 What percentage of your claims are uncollectible?

Select one Less than 5% 5% 10% 15% 20% More than 20%

 Do you use a collection agency?

Yes   No

 What percentage of your claims are 30-60 days out?

  Select one Less than 5% 5% 10% 15% 20% More than 20%

 Do you process your own patient statements?

Yes   No

 Do you review your fees/codes annually?

Yes   No

 What improvements would you most like to see in your billing process?