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Please provide the following information if you are interested in a free consultation.

	Physician Name/degree
	Name of practice
	Specialty
	New or established practice?	New Established
	If a group practice, how many physicians or providers require our services?
	How many office locations do you have?
	How many active patients?
	Number of patients seen per day
	Average number of claims per month
	Average billed amount per claim
	Percentage of office claims vs. surgical in or outpatient claims
	Office contact name
	Title of contact
	Phone number
	Street address
	Building or suite
	City
	State
	Zip
	Phone
	Fax
	Email
	Date you wish to begin billing operations
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