Information Request

Getting answers to your questions is simple. Fill out the form below with as much information as possible and we'll get back to you as soon as we can.

All fields that are required to submit the survey are marked. PracticeMax does not sell or share any personal information that you give out to us.

Gereral Information

Name (Required):

Title:

Company:

Address:

City, State, & Zip Code:

Telephone #:

Fax #:

E-mail Address (Required):

Service Interests

Please select at least one service

  • Patient Scheduling
  • Consulting & Training
  • Insurance Verification
  • Financial Services
  • Billing Services
  • Patient Outreach
  • AR Follow-up
  • Payroll & HR
  • Compliance Programs
  • Credentialing/Registration

Company Information

Charges:

Capitated:
Non-capitated:
Total:

Collections:

Capitated:
Non-capitated:
Total:

Number of Providers:

Physicians:
PAs/NPs/Other:

Payor Mix (%):

Medicare:
Medicaid:
HMO:
Commercial:
Self-Pay:
Total:

Patient Visits:

Number of Visits:

Existing AR Balances:

Total Charges Outstanding:
Total Accounts: