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Medical Billing Form

Your Name
Your Email ID
Phone Number

1. Type of practice/business are you looking to obtain medical billing service?

Physician office (family practice, medical clinic, etc.)

Medical billing service company

Hospital

Physical therapy practice (chiropractic office)

Psychologist practice (mental/behavioral health)

Dental practice

Medical equipment company (DME)

Other (please specify):

2) Do you currently utilize the medical billing service inhouse or to local vendors?

No - our practice/business does not currently use medical billing

No - this is for a new practice/business or office

Yes (please indicate which solution, if known):

Not sure

3) Which practice management are you looking to address the medical practice?

Billing and collections

Appointment scheduling

Insurance claim submission/management

Electronic medical records (EMR)

Patient records management

Reporting

Other (please specify)

4) How many practitioners or billiable providers needs the medical billing service?

1-2

3-5

6-10

11-25

25+

5) How many business locations or clinics, service is rendered?

5-10

10-20

15-20

20-25

25+

6) When are you planning to implement the Live work?

Immediately

Within two months

Between two and four months

More than four months

7) Additional requirements