Name *
Office Phone Number *
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Date *
Address *
Line 1
Line 2
City
State
Zip Code
Country
Notes *
Company Name *
Direct Phone Number *
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Email *
How do you file your claims? *
A full-time staffer does this for me A part-time staffer does this for me I do it myself It is outsourced
What is your estimated wait time to have a claim paid? *
2 to 4 days 5 to 7 days One week 10 days 14 days 30 to 60 days
What is your cost to file per claim? *
Less than $1 per claim Between $1 and $2 per claim Higher than $2 per claim
What is the average number of claims per month? *
Fewer than 50 50 to 100 101 to 500 More than 500
Would you be interested in having another company do your medical billing? *
Yes No
If not, what might change your mind? *
Lower rates Quick reimbursements Better service and treatment Faster claims filing More/better collections
What services would you like to see a medical insurance biller (MIB) offer? *
Thank you for taking the time to fill out our survey.  We look forward to working with you and your team.
If you have indicated that you would like to see improvements in your medical billing practices, I will contact you with a better offer than what you are currently receiving from your present MIB.

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