BURKS MEDICAL CONSULTING APPLICATION

Please print out this application. Complete one for each location and/or physician in your
practice. Fax the completed application(s) to 214-556-1645.  We will call you with a quote or
call you to set up a meeting.  Afterwards, a contract will be forwarded to you for signature. The
application process takes about 2 days. If you have any questions, please give us a call at
682-518-9300. Thank you in advance.

Date: _____________________________________________________________

Name of Provider: ___________________________________________________

Specialty: __________________________________________________________

Name of Practice/Office:_______________________________________________

Address of Practice: _________________________________________________

               ______________________________________________

               ______________________________________________

Phone:                 ___________________________________

Fax:                 ___________________________________

Tax ID#: _______________________________________

Name of point-of-contact in your practice with whom BMC will
Co-ordinate billing operations: _____________________________________

Point of contact Phone number: _________________________________

Point of contact E-Mail Address: ______________________________________

Type of Practice: ___________________________________________

Type of service in which you are interested: (check one)_________Billing/Collections
________Marketing _______ Practice Set-Up ________Staff Recruitment _______Recruiting
_________Pre-Authorization Service _________EEG Services _________Other

Date you wish BMC to begin services: __________________________

If interested in outsourcing your billing, what is the Approximate Monthly Payment Volume:
$____________________

If interested in Pre-Authorization Services, how many MRI's and/or CT's do you see a week?
_____________________

Is your business a start-up or existing practice: □ Start-up     □ Existing

If your practice is existing, why are you looking to change companies?
________________________________________________________________________