Free Billing Service Rate Quote

In order to give you your free, instant price quote, we need some information about
your practice.

Free Billing Service Rate Quote

Note: We will never contact you without your permission, or share your information with anyone else.


Practice Information
First Name:*
Last Name:*
Practice Name (if dif.):(Optional)
E-Mail:
Address1:
Address2
City:
State:
Zip:


Phone:* Ext.


Do you have a website? Yes No If so, please enter it here:
Type of Practice (e.g.: surgery, anesthesia, OB, mental health, etc.):
Number of Practitioners
Volume & Income Information, and Billing Preferences
When giving the information for volume and income, please only consider claims and income for which
you will want us to do the billing.

Volume (claims per week)
Please enter the approxmiate number of claims you will want us to bill per week
Income
We need to know the average dollars per claim, the average gross income per week, or the average
gross income per year.
Please select one of the following:

Average dollars received per claim. Please enter amount collected, including co-pay. Not amount
billed.
Average gross income received per week
Average gross income per year

Services

Number of $ indicate how expensive each service is.
Please check off the services you would like us to include in your quote.
Note: you will have the opportunity to see how different choices effect your quote on the next page.
Bill out all insurance claims, and follow up on any unpaid or denied claims
Keep track of authorizations/prior approvals and notify you when they are running out $
Perform insurance verifications prior to first visit $$$
Track amounts owed by patients and mail bills to them $$
Take phone calls from patients to discuss balance or insurance questions $$
Take phone calls from various practitioners in your group to answer billing questions $
Manage deposits for your practice $$$
Will you require specialized or unusual reports? $

Note: we also offer coding and practice consultation services. These are priced separately.

Additional Information

How did you hear about us?
I would like to start
Currently my billing is handled by:
I am looking for a billing service because (please check all that apply):
I want to increase revenue
I want to save time
I hate dealing with billing
I want to reduce billing errors
I am unhappy with our current biller
Other



Do you have any other questions or comments?

As mentioned above, we will never contact you without your permission, or share your information with anyone.
Please check one or more boxes below:
Please call me
Please e-mail me
Please send me a brochure
Please put me on your mailing list to receive notification of future speical offers and discounts.
Please send me a start-up packet. (Checking this box gives us permission to contact you.)
Please do not contact me at this time.

If you would like us to contact you, please make sure the contact information above is correct.



Your Full Service Billing Partner
Call us toll free at (800) 811 1882 Ext. 2201 or email info@usemedibill.com