PLEASE PROVIDE THE FOLLOWING INFORMATION TO RECEIVE A CUSTOMIZED QUOTE:
CONTACT INFORMATION:
Name
*
Title
Email
*
Phone
Preferred Method of Communication
Email
Phone
Either
PRACTICE INFORMATION:
Practice Name
*
City
*
State
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Primary Specialty
*
Select
None
Plastic Surgery
Dermatology
General Surgery
Ambulatory Surgical Center
Anesthesia
Endocrinology
ENT
Chiropractic
Mental Health
Other
Other Specialty (Primary)
Secondary Specialty
Select
N/A
Plastic Surgery
Dermatology
General Surgery
Ambulatory Surgical Center
Anesthesia
Endocrinology
ENT
Chiropractic
Mental Health
Other
Other Specialty (Secondary)
Number of Locations
*
0
1
2
3
4
5
6
7
8
9
10
More than 10
Number of Physicians
*
0
1
2
3
4
5
6
7
8
9
10
More than 10
Number of Mid-Level Providers
0
1
2
3
4
5
6
7
8
9
10
More than 10
Average Number of Office Visits Billed to Insurance (Weekly)
*
0
1-10
11-25
26-50
51-100
More Than 100
Average Number of Surgical Cases Billed to Insurance (Monthly)
*
0
1-10
11-25
26-50
51-100
More Than 100
Average Monthly Receipts (Non-Cosmetic)
*
Current Billing Software
*
INSURANCE PARTICIPATION: (Select all that apply)
*
None
Medicare
Medicare Replacement Plans
Medicaid
Medicaid Replacement Plans
BCBS
Commercial (Aetna, Cigna, Humana, UHC)
Liability
Worker's Compensation
Self-Pay/Uninsured
INTERESTED IN: (Select all that apply)
*
Medical Billing
Coding
Clinical Documentation Review
Outstanding A/R
Surgical Prior Authorizations and Pre-Determinations
Benefits & Eligibility
Financial Cost Estimates
Insurance Credentialing & Contracting
Hospital Credentialing & Reappointments
Practice Management Services
ADDITIONAL INFORMATION OR QUESTIONS:
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