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Group Purchasing Program Questionnaire

AIH Advantage Program

Your Name *

How do you want us to contact you?* *

Email *

Phone Number *

please place a checkmark next to the advantage program vendors you are currently utilizing.

Accurate Data
Copy-Pro
Office Depot
Accurate Data
Copy-Pro
Office Depot

VENDORS NOT LISTED ABOVE THAT YOU ARE CURRENLTY UTILIZING:

MED-MAL:

Rate carrier:

Specialty:

Voice dictation supplies & software:

Current equipment & cost:

Do you need help designing or updating your website?

Yes
No

Is required red flag plan in place?

Yes
No

Is required red flag plan in place?

Plan submitted for 2% bonus
interested in solution for 2% bonus

Imaging supplies & equipment:

Office equipment:

Phone & internet service:

Cost

Pay roll:

Cost

Health

Life

Disability:

HSA

Current carrier:

Cost

What Colour is the Sky? *

( Anti-spam Question)

AIH contracts directly with employers and other health care consumers as a credentialed network of physicians

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Contact us

1209 Arendell St Morehead City NC 28557
(252) 514-0057
bwillis@aihinc.com

Services

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Medical Management

1Information About You

2More Information About You

3Your Payment Information

Legal Name *

First

Middle

Last

Email *

Phone *

How Did You Hear About Us? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Billing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Membership

Don't enroll me as a patient, I'm paying for someone else.

Date of Birth *

Sex *

Plan *

Total

$ 0.00