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Provider Questionnaire

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Tell Us About Your Practice

Practice Name & Contact Person*

Phone Number*

Email*

Do you currently accept insurance?*

Number of Providers in Office*

Specialty & Location*

Average Number of Weekly Claims*

What EHR do you currently use?*

Do you need Past Due Accounts cleared?*

Is Credentialing and/or Contracting Needed?*

Were you referred? By whom?

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