310 E Second Street
Delphos, KS 67436
(877) 212-2642

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Please provide the following contact information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

Are you interested in temporary or permanent services? (Choose one.)

Temporary
Permanent

Which medical billing services are you interested in? (Check all that apply.)

Complete practice management
Electronic filing of healthcare claims
Paper filing of healthcare claims
Posting of payments
Clean up of aging claims
Ambulance providers only: Access to electronic medical records

Which description best fits your practice?

Ambulance Service
Chiropractor
Assisted Living Unit
Medical Services Association
Counselor
Neurology
Other

If you entered other, how would you describe your practice?

How many claims does your organization process each month?