Response Form

** Items Marked with an asterisk (*) are required.

*Name:
Company:
Address:
City:		State:
ZIP:
Phone:		Fax:
*E-mail address:
Specialty:
How many providers in the practice?
Are you currently outsourcing your billing?		yes no
How did you hear about us?
What services do you need? Mark as many as apply:		Billing Service CPT Code Usage Documentation Review Documentation Training Process Old Accounts Receivable
In the text box below please tell us more about your needs or submit questions to be addressed.

2805 East Oakland Park Blvd.

Suite 354

Fort Lauderdale, FL 33306

(800) 764-2467
954-566-3888

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