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Organization Information
Tax Id: Org Type:
Address 1:
Address 2:
City: State:
Contact Information
First Name: Last Name:
Job Title:
Phone Number: Email:
Electronic Information

General Information
What clearinghouses do you currently interface?

Other clearinghouses not listed above?
What is your Practice Management Software?
Please list top 5 payors you interface with?
Payor Volume
Would you like to be contacted for an AdminisTEP demo?