REQUEST for QUOTE
(NO OBLIGATION)

ALL INFORMATION WILL BE HELD IN STRICTEST CONFIDENCE

 * = Required Information
N/A or 0 (zero) is usually acceptable where a question is not applicable to your practice.
The more info you provide, the more accurate we can be.

*Name

*Name of Practice"same" is acceptable

*Street

 Suite

*City, *State Select AL AK AZ AR CA CO CT DC DE FL GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NJ NE NH NM NY NV OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY *Zip

*Email address
*Confirm email address

Day time phone number--

*Specialty

*Year Established    *Number of Physicians

*Number of Physician Assistants,  Technicians, Therapists or other personnel which are eligible for insurance reimbursement;

*Average number of Office Patient Encounters per day   x days per week

 *Average number of Hospital Patient Encounters per day      x days per week

 Billable Ancillary Services (xRay, supplies, etc);
 

*Number of billable ancillary services per day

*For the most recent 12 month period approximately what percentage of the practice income was generated from; 

*Medicare %   *Blue Shield %   *Other commercial insurance companies % 
  *HMO’s %   *What portion of HMO payments are for Fee for Service%

*Gross Practice Income for most recent 12 months.  Include only income which you would like us to consider as a part of this billing service application. $

*In the next 12 months you expect practice income to Select One Increase Decrease No Change

*Percent of change expected %

 Reason for above change

Comments, Requests and additional information;

*Name of Person completing this application *Title

*Contact person (if same as above enter "same")

*Contact via Select One eMail Mail Phone

Would you like to be added to our emailing list? Yes

Would you like to receive emails about special offers from our affiliates? Yes

Upon receipt of your application we will generate a formal written proposal based on the information you supply, usually within 48 hours or less.  If you need a rush please indicate it in your comments above.  All information will be held in strict confidence. If you prefer, you may print this application and mail or fax to us.  Our address and fax can be found on the Contact Us page.  Thank you.