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Physician's Name Address: City: State: Zip Code: MO AL AR AZ CA CO CT DE FL GA IA ID IL IN KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT WA WI WV WY VA Phone # Do you experience rejected claims?   Yes No What percentage of all claims are rejected (Medicare, Medicaid, Commercial)   0%-10% 10%-20% 20%-30% More than 30% How does your office process claims?   Manual Electronic If electronic; Are you processing:   Medicare   Yes No Commercial Carriers   Yes No What percentage of claims are Medicare?   0%-10% 10%-30% 30%-60% More than 60% If you are processing claims manually:   Do you use a computer to generate forms?   Yes No Do you fill in claims manually?   Yes No Do you use an outside service to process claims?   Yes No Are you satisfied with this service?   Yes No Do you find filing insurance claims time consuming?   Yes No Would you like to reduce the turn around time on insurance payments?   Yes No Would you consider an outside service for processing claims electronically?   Yes No Is your software compliant to HIPAA standards?   Yes No Would you be interested in software for your practice?   Yes No