Practice Assessment

Please take a few moments to tell us about you and your practice. An ancillary specialist will evaluate your practice and contact you to review potential solutions.

Practice Contact

Your role *
Select your State *
Your name *
Zip Code *
Email *
Phone *

Practice Information

Area of Practice
Number of Practitioners? *
Average number of patients daily? *

Payor Mix

Please provide approximate % for each payor type.
PPO
HMO
Medicare
Medicaid
Self-Pay/Cash
Workers' Comp

Verification

Please enter any two digitsExample: 12
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