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Billing Intake
Help us serve you better
Provider Name (Full Legal Name & Credentials):
*
Email address
*
Practice/Entity Name:
Phone number
Practice/entity address
Type of practice
Select
Private Practice
Group Practice
Non-Profit
Specialties offered
Please select at least one option.
Psychiatry
Psychology
Social Work
Counseling
Therapy
Number of patients served
Select
1-50
51-100
101-200
201-500
500+
Preferred contact method
Select
Email
Phone
Text
How did you hear about us?
Select
Referral
Search Engine
Social Media
Event
Average Monthly Gross Revenue:
Estimated Monthly Claim Volume:
Top 5 CPT Codes Used:
Insurance Networks
Please select at least one option.
AETNA
BCBS
CIGNA
MEDICAID
MEDICARE
TRICARE
UHC
Any Current Credentialing/Pending Contracts?
Current EHR/Practice Management System
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