Medical Billing Resources, Inc.

We invite your inquiries. Should you have any questions, or just wish to talk with a client representative, please complete the following form. You will be contacted promptly.

Last Name

First Name

Title

Facility or Practice Name

Street Address

City

State

Zip Code

Phone

Fax

E-Mail

Best time to contact you

Please identify the type of service you are interested in discussing-

	Billing and receivable management for group practice (REAP)
	Billing and receivable management for faculty practice (REAP)
	Aged receivable support for a physician billing operation (CMP)
	Aged receivable support for inpatient hospital (CMP)
	Aged receivable support for outpatient hospital (CMP)
	Management and wind-down of a pre-conversion receivable (Safety Net)
	Billing and receivable management for emergency transport services (TPP)
	Electronic medical records / Scanning services

For a free evaluation

Please provide as much of the following information as possible, answering the questions that most appropriately apply to the project you are considering:

Specific hospital services, or medical specialties considered
Is appointment scheduling desired?	Yes No
Is patient registration desired?	Yes No
Will system access be desired at your site for inquiry?	Yes No
Payer mix information concerning the targeted patient population
The healthcare billing system presently utilizing
Annual number of patient accounts (encounters) to be referred
Number of healthcare providers in the group
Number of tax I.D. numbers utilized for billing
Account age targeted for routine monthly referral
Are self-pay accounts to be included in the project?	Yes No



This information will be held in strict confidence, and evaluated prior to making contact with you.

Thank You