Contact Me

Name *

First Name

Last Name

Phone *

(###)

###

####

Licensing Information *

LCSW

LPC

LMFT

PhD

MD

Other (will list in the Message field)

Length of Time in Current Practice *

Less than 1 year

1 – 3 Years

3+ Years

Average Number of Patients Seen Each Month *

1 – 9

10 – 29

30+

Are You Currently Submitting Claims Electronically? *

Yes

No

What is Your Current Billing Situation? *

Submitting own claims

Not yet submitting claims

Using other billing agency

Using current staff

Other (will explain in the Message field)

Are You Established with the Major Insurance Networks in Your Area? *

Yes

In the Process

No