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Dear Client,
Thank you for your interest in Claims Med. This form serves as an initial assessment of you and your
business, and helps us get us a better idea of the best way we can be of service.
*
Indicates required field
My business is
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a start-up
established
My practice will function as
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an Individual Provider
a group
Legal Business name
*
Doing Business As
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Federal Tax Classification
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Individual/sole proprietor or single member LLC
C Corporation
S Corporation
Partnership
Limited Liability Company
If Limited Liability Company, please enter the tax classification
*
C=C Corporation, S=S Corporation, P=Partnership
NPI (if any)
*
My business has a physical location where we see patients.
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Yes
No
If Yes, my business is located at
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Line 1
Line 2
City
State
Zip Code
Country
Number of physical locations
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Number of Individual Healthcare Providers
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We will be requiring Provider Credentialing Services
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Yes
No
Average patient flow per day (all locations included)
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The Practice Management Software we currently use is
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We wish to continue using our current software
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Yes
No
Contact Person Name
*
Contact Person Designation
*
Contact Person Phone
*
Contact Person Email Address
*
Comment
*
Submit
Features
Why Choose Us?
Consulting
Security
About
Services
Provider Credentialing
Medical Billing Services
Denial Management
Request a Quote
Blog
Contact
WIKI
Multimedia
Login
