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Request a Quote for EZClaim Clearinghouse Services

Complete the information below and an EZClaim rep will contact you with EDI pricing options.

* Designates a required field

Current EZClaim Customer?	Yes No
*Name:
Name of Practice:
Name of Provider:
*Contact Phone:
*Email:
Fax:
Preferred time of Contact Days:	M Tu W Th F Morning Afternoon
*Number of Providers to enroll:
Approx number of claims per month:	1-100 101-250 251-500 501 +
Are you currently submitting claims electronically?	Yes No
If yes, current Clearinghouse or Payer:
What type of claims do you send?	All Medicare Medicaid Blue Cross/Blue Shield Commercial Only
How did you hear about EZClaim?	Web Search Advertisement Referral Friend/Colleague
Type of program? (Provides quote for each type selected)	Desktop Remote

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EZClaim Healthcare Software

337 S. Main Street Ste 200
Rochester, MI 48307
Phone: 877-650-0904
Fax: 248-651-9273
Email: sales@ezclaim.com

Clearinghouse Support