BPM Forms Hosting Site - Medinol Getting Started Page

Confidential Getting-Started Form

Your name, please*
Name of your practice*
Select your practitioner type*
Practice Number*
Phone Number*
Email address*
Communication preference*
Physical location?*
Operating phase of your practice*
How are you currently claiming from patients/medical aids?*
Name of billing system are you currently using for your claims?*
Most annoying issue(s) behind non-payment of your claims?*
Billing system preference*
Computer available deployment*
Please note: Medinol runs natively on only 32-bit architecture.
When do you need to be up-and-running by?*
YYYY slash MM slash DD

Please allow at least four days from signed order to submitting claims.
Next step*
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