Please complete this short form. This will allow us to know more about your organization and reply back with additional information. LCDirectBilling Inc., will contact you within 24 hours to elaborate on our services and work towards establishing a win-win relationship with your organization.

Full Name*

Contact Email*

Practice or Physicians Name*

City*

State

Zip Code*

Contact Phone Number*

Fax

How many providers are in your office?*

Practice Specialty*

How are you currently processing claims?*

ManuallyElectronicallyBoth

How is your billing currently being done?*

In-HouseOutsourcedBoth

Are you currently contracted with insurance companies?*

Contracted with most carriersContracted with some carriersNot contracted with any carriers

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