Would you like to know more about AMCA?  Please contact our staff by telephone or email and we will be happy to help determine the perfect solution for your business needs.

P.O. Box 1237
Liberty Hill, TX  78642
Office: (512) 515-0065
Fax: (512) 515-7785

If you are interested in a quote, please fill out the online form below.  Once completed, simply click the "Submit" button and a member of our staff will contact you within one business day. You can also download the form and fax or email it in if you prefer.
Download Form

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Provider/Group Name:
*Contact first name:
*Contact last name:
*E-mail address:
Phone #:
Street Address:
1. How many providers are in the practice?
2. Are the providers part of a group or do they practice individually?
Group Individual
3. How many total patients are seen per week?
4. (a) Are there any procedures done in office i.e. lesion removal, skin tag removal, etc?
Yes No
(b) If so, how many per week and what types of procedures?

5. Are patients seen outside of the office i.e. hospital, nursing home?  Yes No
6. What is the average charge per office visit?
7. What is the average charge per procedure, if applicable?
8. (a) What insurance plans are accepted?

(b) What is the estimated percentage of your patient base for each plan i.e. 50% Medicare, 30% PPO, etc.?

9. (a) Average of the last 3 months total monthly charges:
    (b) Average of the last 3 months total monthly receipts (including co-pays):
    (c) Current outstanding accounts receivable:
10. Number of office personnel and years employed:
11. Are insurance benefits and eligibility verified at the time of service?  Yes No
12. (a) Is there a staff member available to prepare billing i.e. prepare deposits, superbills and patient information for the billing service? Yes No
(b) Will this be the same person who verifies insurance benefits?  Yes No
13. (a) Who is responsible for coding diagnosis and procedures for billing?
(b) If not coded by the physician, is the coding reviewed by the physician?  Yes No
14. Are co-pays and/or co-insurance collected at the time of service?  Yes No
15. (a) Does your office currently perform the billing in house?  Yes No
(b) If so what software are you using?
16. Should you decide to use our services, what is your anticipated start date?
17. If you have any special requests or questions, please feel free to use the comment box below provide us with more information so we may better serve you: