Select one of the options below available for enrollment online.
View the links to get more information about each option. Or Contact Sales for more information.
Company Name*
Contact*
Address*
Ste:
City*
State *
Zip*
(Area)+ Phone*
(Area +) Fax:*
Email*
Web Site URL:
Specialty*:
Average Number of Patients Seen Daily? 1-10? 11-20? 25-45? Over 45?
Current Software System? (if none, Leave Blank)
Number of Staff Physicians or Other Providers?
Would you be using the Encounters Claim Submission Software? Yes No Unsure Help (If you choose "help" we will send you more information on our software).
Briefly Describe your goals for 1 Claim Source? How Can we service the needs of your company? What are your major concerns with your business?
