Mid VT Medical Billing - Free Evaluation

Fields Marked With * Are Required Personal Information : *Name:	Name of Practice:	Address #1:
*Email:	Contact Name:	Address #2:
*Phone:	Best Time to Contact:	City:
Fax:	Contact Phone:	State:
	Specialty Type:	Zip Code:
Comments:
Practice Information : We have an: In-house Staff Billing Company	File Claims Electronically: yes no	Number of Providers in Practice: 1 2 3-5 6 or more
Approximate number of patients seen per month: 50-100 100-200 200-500 500 or more
Current Cost of Billing: Weekly cost of In-House Staff:	Monthly cost of Billing Service:
Insurance Information: What is your average turnaround on insurance claims? 15-30 days 30-60 days 60-90 days Over 90 days	Approximate percentage of unpaid claims due to filing errors: 5% 10% 15% Over 20%	Approximate percentage of claims uncollectable: 5% 10% 15% Over 20%
Average Value per claim:	How do you feel about your present method for billing? Satisfactory Needs Improvement Unsatisfactory
CASE SENSITIVE	Image Verification: Change Image