1. What does your practice specialize in?
   

2. How many physicians are in your practice?
   

3. Average number of claims per week total (all claims all doctors)?
   

4. Do you participate in 3 (three) or more of these insurances?
   Medicare, Blue Crosses, Aetna Products, Alliance Products, Workman's Compensation
   Yes
   No

5. Are you interested in our company assisting you with insurance appeals and/or claims follow-up?
   Yes
   No
   Maybe

6. Are you interested in our company posting your EOB's and billing your patients bills?
   Yes
   No
   Maybe

Your Contact Information:

Name:
Phone:
Email: