US MEDICAL BILLING INC

294 W MERRICK RD

STE 6

FREEPORT, NY 11520

TEL: 516-771-7222

FAX: 516-377-7098

           

                                                                                               

                                                                                   

**Please print, sign and fax this form back to 516-377-7098**

 

 

 

Congratulation you have been selected and approved to participate with

 

US MEDICAL BILLING FREE TRIAL PROGRAM

 

You are enrolled for the free trial program for 30 days will start

From __/__/____ through __/__/____

 

All of the payment you will receive through this period as a result of our transmissions to any insurance company will be:

 

FREE WITH NO CHARGE

 

Starting on __/__/____.  A ___% charge will be applied.

 

 

Us Medical Billing Inc.,

294 W Merrick Rd Ste 6

Freeport, NY 11520

516-771-7222                                                                                                            

Signature: _______________           

Dr

 

 

 

Signature: _____________

 

 

                                   

 

 

**Please print, sign and fax this form back to 516-377-7098**