Name of Provider :

Telephone :

Cell :

Email Address:

Specialty:

Number of Providers:

Number of Locations:

Name of Existing Practice Management Software:

Name of the Existing EMR

Billing Software Access Required:

EMR Software Interface Required:

Average Monthly Charges: 

Average Monthly Payments: 

A/R as of today:

A/R to Be Converted :

Total Charges: 

Total Insurance Adjustments: 

Total Charge Adjustments:      

Total Personal Payments: 

Total Insurance Payment:

Procedure Analysis Report:

Current A/R by Financial Class: