Practice Name:

Specialty:

Physician’s Name:

Contact Name:

Phone Number:

E-mail Address:

Mailing address:

How many patient visits do you have per month?              

What is the average collections per month?                         

Are you a contracted HMO provider?

Yes

No

Are you a contracted PPO provider?

Yes

No

When was the last time you reviewed your contracts and fees?

Why are you considering a new billing solution?

Any additional symptoms we should evaluate?

Electronic Signature

By entering your Name in this box and submitting this information, you hereby authorize this information to be disclosed to Pacific Practice Management ONLY. This information shall not be released to any other party unless written authorization is obtained from you. Pacific Practice Management will treat this information as strictly confidential.