Type of Business:
How long have you been in business?
How many new patients per month?
What is your average/estimated DME billing per month?
What is your annual revenue?
Do you have a DME License?
Are you Medicare Certified?
Do you plan to bill Medicare?
In what state(s) would you like to do business?
When can we reach you?
[date* best-date date-format:mm/dd first-day:1 change-month placeholder "mm/dd"]
Questions or Comments?