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Please enter your practice procedure codes in the
fields provided below:
Note: Use your tab key to
advance to the next field
Tell Us
About Your Practice:
Type of Practice/Facility:
Practice/Facility Name:
Address:
City: State:
Zip Code:
Telephone Number: Fax Number:
Name of Practice/Facility Medical Director:
Name of Party Requesting Analysis:
Email Address:
Web Site Address (if avail.):
I understand that DRbilling.com will
invoice my practice/facility $75.95,
for a procedure code
analysis of up to 40 codes and $0.50 each additional code:
(Please enter X in the box)
Please allow 2 weeks for
delivery
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