First Name *
Last Name *
Email *
Phone
Company *
Company State * AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Title *
I am a... * Provider Payer Other
What are you interested in? * (Payer) Clinical Data Exchange (Payer) Gateway Services (Payer) Improve Authorizations Process (Payer) Managing Provider Data (Payer) Provider Portal (Provider) Add more payers to my existing Essentials account (Provider) Consolidate all revenue cycle processes into one single flow (Provider) Prevent denials while managing and tracking claims through an intuitive user interface (Provider) Request help with my current Availity account or services (Provider) Subscribe to clearinghouse services Submit RFP-RFI Other
What is your current membership? (How many covered lives do you serve?) *
On average, how many claims do you receive each month? *
What is the estimated number of clinicans/providers in your network? *
Do you currently have a provider portal? * YesNo
Do you currently have gateway connections in place? * YesNo
What Practice Management/Billing Software do you utilize? *
Please include any other details that you think would be helpful for our conversation: *
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