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Complete a Simple Questionnaire and Get a Free Quote

Please fill out and submit the form below or you can download the form in PDF format and fax to Anthony F. Maniscalco at 813-884-8355 or email it to us at information@mdtechnologies.com.

Contact:
Name of provider:
Telephone #:
- -
Cell phone #:
- -
*Email:
Specialty:
Number of providers:
Number of locations:
Name of existing practice management software:
Name of existing EMR:
Require billing software access:
 Yes No
Require EMR software access:
 Yes No
Total average monthly charges:
Total average monthly payments:
Total A/R as of today:
Require existing A/R software conversion:
 Yes No
Current system report reflecting monthly average:
Total charges:
Total insurance adjustments:
Total charge adjustments:
Total personal payments:
Total insurance payment:
Procedure analysis report:
Current A/R by financial class:
Note: The free quote you receive will be contingent upon receipt and verification of all requested information.