Legal Business Name *

Owner's Name *

Business Email *

Business Phone *

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

Company Website

When was your business started?

Is your business currently affiliated with any major associations? (HBMA, MGMA, AAPC, etc.)

If so, please list those associations below...

Do you currently have billing clients or are you a new business?

Please list any specialties that you have experience with...

What sized clients are you willing to work with? (Keep in mind this will limit volume)

How many US based billers do you currently employ?

Is your US based workforce W2 or 1099?

Do you currently have offshore support for your billing company?