Custom Profile Form

Completion of this custom profile will enable us to give an accurate quote on medical billing services specifically for your needs.
 

Office Name:

 
Address 1:

  
Address 2:
City/Town:  State:  Zip:
Telephone:  email:
Specialty: 
 
Number of Providers:    
Contact Person:      
1. Number of Active Patients: 

2. Total number claims per month: 



% Medicare 

% Commercial 

% HMO/Managed Care
 

% Medicaid/W.C., PI
  
% Other

3. What percentage of all claims are rejected: 

4. What is the average dollar amount of a claim? 

5. Do you currently submit electronic claims? 

6. Would you like further information on: 

Briefly describe the nature of the problem you would like assistance with and any comments:

Thank you for your inquiry.  A Peak Healthcare Solutions representative will be in touch with you regarding your confidential medical services quote. 

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