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First Name *

Last Name *

Company *

Are you a medical billing company? *

Yes

Industry *

Please Enter Other Industry: *

No collection efforts will be made on accounts under $100 dollars.

Number of Accounts for Collections *

Average Balance of Accounts *

How often will you send us accounts? *

How many accounts will you send us per month? *

Email *

Phone *

Message (Optional)

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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