Pre-Qualification Form

This form is just for our billing agents to be able to calculate a rough estimate of what you would need per month and how much it may end up costing you. We want to make sure you get what you need at a fair price. Filling out this form will help us and you to work together to that end.

After you submit and send the form, we will get back with you soon to respond with the requested information.

Contact Info



Your Phone Number


Highest Number per Day

Highest Number per Week

Highest Number per Month

Lowest Number per Day

Lowest Number per Week

Lowest Number per Month

Monthly Minutes of Talk Time (this may be obtained from your phone carrier/bill) if possible

Practice Info

Number of Claims Billed out Each Month

Highest Revenue Month

Lowest Revenue Month

Average Number of Patients Seen per Week

Average Charge per Patient

Extra Notes