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Your Name
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Phone Number
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1) For what type of practice/business are you looking to obtain medical billing service?
Physician office (family practice, medical clinic, etc.)
Medical billing service company
Hospital
Physical therapy practice (chiropractic office)
Psychologist practice (mental/behavioral health)
Dental practice
Medical equipment company (DME)
Other
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2) Do you currently utilize a medical billing solution?
No - our practice/business does not currently use medical billing
No - this is for a new practice/business or office
Yes (please indicate which solution, if known):
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Not sure

3) Which practice management functions are you looking to address with this medical practice solution?
Billing and collections
Appointment scheduling
Insurance claim submission/management
Electronic medical records (EMR)
Patient records management
Reporting
Other
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4) How many practitioners or billable providers will you be managing with this medical billing service?
1-2
3-5
6-10
11-25
25+

5) How many individual office or business locations will be using your medical practice solution?
5-10
10-20
15-20
20-25
25+

6) Approximately how many users will need access to your health care billing solution?
1
2
3-4
5+

7) When would you like your medical billing solution implemented?
Immediately
Within two months
Between two and four months
More than four months

8) Other than price, what is most important to you when selecting a medical practice management solution?
Features and functionality
Ease of use
Customization
Service (installation, training and support)
Scalability
Other
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9) Please briefly describe in detail any additional requirements you have and the specific nature of your office or business.
   
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