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Please answer the medical billing questions below so that we will know more about your practice and your specific needs. One of our sales representatives will contact you to see if our services are a good match for your practice.

URL
This field is for validation purposes and should be left unchanged.
Name*
First Last
practice name (if different)
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
fax number
website url
This field is hidden when viewing the form
website url (old)
Type of Practice*
Number of Practicioners
When giving the information for volume and income, please only consider claim and income for which you will want us to do billing. Also note that the income figures are for amount your receive (on average), not the amount you bill out.
approximate number of claims you will want us to bill out per week
the average amount that you will receive (not bill out) $ per claim
How did you hear about us?
I'd like to start
Currently my billing is handled by
I’m looking for a billing service because (please check all that apply)
- I want to increase revenue
- I want to save time
- I hate dealing with billing
- I want to reduce billing error
- I am unhappy with our current biller
- Other
Do you have any comments or questions?

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