Electronic claims processing for the healthcare industry.

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Gateway EDI Services Email Form

Please use the Tab key to move to the next box on the form. Do not press the Enter key, as this will automatically send your form before you have completed it!

When you click the button at the bottom of this page, your answers will be E-mailed to a sales representative, who will contact you as soon as possible. Please respond only to the questions you are comfortable answering, but provide enough information so that we may give you details about the Gateway EDI products that interest you. Thank you for taking the time to complete this form. We look forward to working with you.

Contact Details:

First Name	*
Last Name	*
Name of Practice
Specialty
Address
Address 2
City
State
Zip
Phone
Fax
E-mail	*

* Required Information: We need at least your name and an E-mail address to be able to contact you.

Additional Details:

Are you currently sending your claims electronically?
Yes No

If yes, what are you sending?
All
Medicare
Medicaid
Blue Cross/Blue Shield
Commercial Only

Who is your current Clearinghouse?

How are you paying?
Per claim Flat fee

How much does it cost each month?

What Practice Management System (Billing Software) are you using?
Not Sure

Who is your vendor?
Not Sure

How many providers in your office?

Approx number of claims per month?

Does your office have Internet access?
Yes No Not Sure

What brought you to our website?
Vendor
Advertisement
Client Referred
Tradeshow - Which one?
Beachball
Pen
Article
Web Search Engine - Which one?
Other

Thank you. Now either

or

and start again.

Customer Login or Call 800.556.2231

We are extremely pleased with the staff and the claims handling at Gateway - Our only regret is that we did not convert earlier.