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Agency Information
Name
Address 1
Address 2
City
State
Zip Code
Agency Contacts
Contacts (Name, Title, Phone Number and Email address)
Programs
Please select the programs / services your agency provides
IDD
Adaptive Aids
Audiology Services
Behavioral Support Services
Cognitive Rehabilitation Therapy
Day Habilitation
Dental Treatment
Dietary Services
Employment Assistance
ICF
In-home Day Habilitation
In-home Respite
Licensed Vocational Nursing
Minor Home Modifications
Occupational Therapy Services
Physical Therapy Services
Registered Nursing
Respite
Social Work Services
Specialized Licensed Vocational Nursing
Specialized Registered Nursing
Speech and Language Pathology Services
Supported Employment
Transition Assistance Services
Other programs / services
Number of monthly claims
(if a claim has multiple units, it should still be considered as 1 claim)
Additional Information
What is your agency's approximate annual revenue?
Which EMR / EHR system (if any) does your agency currently use?
Which EVV system (if any) does your agency use?
Are you also interested in a quote to outsource the billing process?
Yes
No
Is there any other information you would like to share with us?
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