Qualifying Questionnaire

We are excited that you have expressed interest in learning more. Once this questionnaire has been completed, we will promptly contact you to schedule an introductory call.

First Name *

Last Name *

Email *

Phone *

Company *

Your Title *

Street Address

City

State

Postal code

Current EMR? Are you planning on staying with your current EMR? If not, what do you plan on transitioning to?

Current billing system? Are you staying with your current system? If not, what are you changing to and what will that be?

Current clearinghouse (if known)?

What’s the biggest challenge you need to solve right now?

Average number of patients per week?

What percentage of your AR is > 60 days?

Who performs your verification of benefits?

I confirm that I want to receive content from this company using any contact information I provide.