Use the form below to let us analyze your existing billing set up and our representative will contact you about how we are able to improve your cash flow.

Provider/Group Name:
Provider/Group Specialty:
Your Name:
Title or Position:
Address:
City:
State:
Zip Code:
Phone:
Fax:
E-mail:
Are You Currently Doing Your Own Billing?	yes no
If so, are you computerized?	yes no
Do you currently have a billing service?	yes no
Are you satisfied with their service?	yes no
Are your patients satisfied with their service?	yes no
Would you like to meet with us to discuss your needs or do you prefer a telephone call?	yes no
How did you hear about us?	Flyer/Letter Word of Mouth Other
Specific Questions, Comments: