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First Name* |
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| Last
Name* |
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|
Title |
|
|
Company |
|
|
Address |
|
| |
|
| City |
|
|
State |
|
| Zip
Code |
|
|
Phone* |
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| Fax |
|
|
Email Address* |
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| |
|
| Do
you currently use an outside billing company? |
|
| If
yes, what company? |
|
|
Approx. revenue |
|
|
Medical specialty |
|
| New
or existing practice |
|
| |
|
|
Average number of patients per month? |
|
|
Average amount billed? |
|
| How
often to you process claims? |
|
|
Comments / Questions / |
|
| |
|
| Have
a sales representative contact me* |
|
| Best
time to contact* |
|
| Send
more information about HMS* |
|
| |
|
