The following information is needed to provide you with an estimate for Medical Billing Services. All information listed below is used for the sole intent of generating a bid as per requested. This information will not be used for any other purpose.

Name *
Email Address *
Address *
City *
State *
Zip *
Phone
Existing Software Package Used
Practice Specialty
Number of MD's in practice *
Number of nurses/
Mid-Levels in practice *
Total accounts receivable as
of last month-end date (Sept 30) *

Year to Date:		  
Date Range *    From:   To:
Gross Charges *
Payments *
Patient Visits *

Percentage of:		  
Medicare in Practice *
Medicaid in Practice *
Non-Insured in Practice *
Managed Care in Practice *
Commercial in Practice *

* Fields marked with an asterisk are required fields

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