Please complete the short form below and a representative will contact you, usually within 24 hours. For even faster service please call us at 229.493.0209 between
8:00 a.m. - 5:00 p.m. EST.


  What solutions are you interested in? Let us know.
____ Practice Management Services
____ Revenue Cycle Management Services
____ Billing Services
____ Pre-Collect Services
How would you like us to contact you?
____ Mail
____ E-Mail
____ Fax

Please let us know where to send your solutions:
Name: ___________________________________________________
Position: ___________________________________________________
Company: ___________________________________________________
Address: ___________________________________________________
City: ___________________________________________________
State: ___________________________________________________
Zip: ___________________________________________________
Country: ___________________________________________________
Telephone: ___________________________________________________
Fax: ___________________________________________________
Email Address: ___________________________________________________

  How would you prefer to place accounts?
____ Paper
____ Fax
____ FTP
____ Email
When do you plan to place accounts?
____ Now
____ Near Future
Please let us know if you have any specific questions or concerns below:













To print this form out, click on "File", then "Print".
Please mail the completed form to:

Accounts Billing Services
300 E. Shotwell St.
P.O. Box 1929
Bainbridge, GA 39818