VisionShare Information Inquiry
	Thank you for your interest in VisionShare. Once we receive the completed form below, a VisionShare representative will contact you to answer any questions you have. We look forward to speaking with you.     * Required Field First Name * Last Name * Company Name * Street Address* City* State * Select One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianna Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Phone Number * Email Address * Your Title Business Type Select One Ambulance Service Ambulatory Surgery Center Behavioral Health Service Billing Service Chiropractic Clearinghouse Clinic Dialysis Center DME EMS FQHC Home Health Care Provider Hospice Hospital Indian Health Services Lab Services LTC-Nursing Home Pharmacy Physical Therapy PMS/HIS Vendor Radiology Rehab Services Rural Health SNF-Skilled Nursing Facility VA VNA PMS/HIS Vendor + Clearinghouse PMS/HIS Vendor + Billing Service PMS/HIS Vendor + Billing Service + Clearinghouse Clearinghouse + Billing Service Other What Intermediaries, Carriers or Medicare Administrative Contractors do you need connectivity to? How many Medicare billers do you have? Select One 1 2 - 3 4 - 6 7 - 10 11 + How many locations do you have? Select One 1-10 11-25 26-50 51-100 101-200 201-500 501-1000 1001-3000 3001-5000 5001-9999 10000+ How many hours do you access Medicare systems per month? Select One NA 0 - 5 6 - 10 11 - 20 21 + How do you send your Medicare claims? Select One Dial-up Modem Leased Line Clearinghouse Billing Agency Paper Other Don't Know How do you currently check Medicare eligibility? Select One DDE PPTN IVR CSI HIQA Through Third-Party Vendor We Don't Number of Medicare claims processed monthly? Select One 1 - 15 16 - 50 51 - 200 201 - 999 1000 + Who is your Practice Management System(PMS)/Hospital Information System(HIS) vendor? Select One McKesson CareMedic Data Systems Group GE Gaffey & Associates CPSI SSI Cirius Group Delta Lewis Cerner Beyond Now HealthMEDX CareCentric MiSys/Allscripts Meditech Medisys California Medical Practice One Other Best day to reach me Select One Monday Tuesday Wednesday Thursday Friday Best time(s) to reach me Select One 8 - 12 12 - 5 Anytime