SERVICE REQUEST FORM


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

 
   

© 2015 Accounts Billing Service of Georgia, Inc. All rights reserved.

Accounts Billing Service and the Accounts Billing Service marks used herein are service marks or registered trademarks of Accounts Billing Service, Inc.
Web design and services provided by WebGraffix Media Solutions, LLC