Providers

Request More Information

Select the solutions of Interest:

Thank you for expressing interest in MDOL’s suite of solutions. Please provide the information below and you will be contacted by an MDOL representative to discuss solutions that are best suited for your office.


* denotes mandatory entries.

*Do you currently use MD On-Line?

*Do you have practice management/billing software?

  

*Customer/Practice Name:

*Email:

*Address (1):

Address (2):

*City:

*State:

*Zip Code:

*First Name of Contact:

*Last Name of Contact:

*Phone Number:

Practice Management/Billing Software Name:

*Specialty:

Number of Providers in Your Practice:

Approximate Non-Commercial Monthly Claim:

Approximate Commercial Monthly Claim:

Do you currrently submit claims electronically?

  

Current Clearinghouse

Approximate Monthly Cost:

Type of Plan:

Are you interested in submitting institutional
(UB04) claims electronically?

  

Are you interested in submitting Durable
Medical Equipment claims electronically?

  

Are you a software vendor?

  

How did you hear about MDOL?

At which conference?