1 Claim Source Online Enrollment

1 Claim Source Online Enrollment Options:

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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.

5% Special Customized Solution Other Special Consultation Only

Company Name*

Contact*

Address*

Ste:

City*

State *

Zip*

(Area)+ Phone*

(Area +) Fax:*

Email*

Web Site URL:

Specialty*:

Average Number of Patients Seen Daily?

Current Software System? (if none, Leave Blank)

Number of Staff Physicians or Other Providers?

Would you be using the Encounters Claim Submission Software? (Not offered during trial period)

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?

Please Note: the information you have just submitted will be kept private. We will not disclose your information to any third party entity. We will utilize parts of this information to customize a solution for your company. Other parts of your information will be used to initiate a set up. You may download our service agreement by clicking here.