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First Name *	Last Name *
Company *	Title
Phone *	Email *
Address	Suite, Office #, etc.
City * State * Zip
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How many physicians are in your practice? 1 - 3 4 - 9 10 - 24 25 - 100 100+ Other
What is your group's specialty?
What practice management system are you currently using?
Does your group currently use an outsourced billing service? Yes No
When did you implement your current practice management and billing system or service? Within the past 12 months 1 - 2 years 3 - 5 years Over 5 years
What is your primary motivation for contacting us? Increase your practice collection percentage Decrease cost of your collection process Speed up collection cycle Improve compliance Improve management reporting capabilities Other
How do you want us to contact you further? Call Mail Email
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