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Name*
First Last
Name of Practice*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
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What is your insurance A/R?
30 Days 31-60 Days 61-90 Days 91-120 Days 120+ Days
What is your Responsible Party A/R?
30 Days 31-60 Days 61-90 Days 91-120 Days 120+ Days
What were your average receipts for the prior year?
What is your specialty?
How many patients do you see per day ?
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