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Practice Name:
Address:
City, State, & Zip:
Phone:
Fax:
E-Mail:
Contact Name:

Practice Specialty:
Are You Currently Filing Claims:
How many insurance claims do you process per month?
What is the average dollar amount per claim?
What type of services are you looking for?
What % of you claims need follow-up or corrections?
Do you currently work with a billing agency?
If so, what price are you currently paying? (optional)
Any other questions, concerns, or comments: