Analysis Request

Patient Receivables Analysis Tool Questionnaire

Please complete the form to request an analysis

How much patient receivable revenue did you generate in the last three completed months?

How much of the revenue generated during those three months did you collect?

How many patient statements did you generate during the last three completed months?

How much did you spend on patient collections in the last three completed months? (Software, payroll, collection agency fees, postage, stationary, credit card processing, etc)

First Name:
Please enter name.
Last Name:
Please enter name.
Company Name:
Industry:
E-mail Address:
Please enter valid email address.
Phone number:
Additional Comments: