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Complete this registration form. All fields are required. Based on your responses, additional information may be requested.
Once you’ve submitted the form, you’ll receive an email confirmation. Follow the link to create your password.
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Tell us about yourself. All fields are required.*

Additional question will appear based upon your responess.

Last Name*

City*

State*

Are you a licensed medical provider?*

Yes

Which best describes your specialty?*

Acupuncture

Chiropractic

MRI

Neurology

Orthopedics

Pain Management

Physical Therapy

Psychology

Neuro-Psychology

Radiology

Surgical

Other

Please describe Other*

Which best describes your role?*

Owner

Medical Staff - Dr, Nurse, etc

Management - Office/practice management, office manager, etc.

Business Office Staff - billing specialist, administrative assistant, etc.

Student

Other

Please describe Other*

Which best describes the medical practice, company, organization, or service?*

Single medical practitioner

Small medical practice group

Small multi-disciplinary practice

Large multi-disciplinary practice (more than 10 medical providers)

Imaging company or imaging specialist

Hospital or medical center

Billing or collection outsource vendor

Bulk lien purchaser or outsource bulk lien management company

State or National Association, Group or Organization

Other

Please describe Other*

What is the name of your medical practice, company, organization, school or service?*

What percentage of your practice involves personal injury patients?*

91-100%

71-90%

51-70%

36-50%

11-35%

1-10%

N/A

What are the issues affecting you the most for the personal injury segment of your practice or company? (Select one or more)*

Low bill payments

Extreme delays in getting paid

Processes and procedures for PI patient matters

Lack of education and training for staff in the area of PI and negotiations with attorneys

Patient attorneys or their staff not responsive

Patient attorneys or their staff being verbally abusive or excessively demanding

Patient attorneys or their staff not fair, reasonable or cooperative in our opinion

Insurers sending MedPay/PIP we apply for to the patient attorneys

Patient attorneys taking attorney fees from MedPay/PIP

Patient attorneys settling cases but refusing to disclose all the settlement details

Patient attorneys assuming lien reductions and not asking prior to the case settling

Out of state patient lawsuits and/or out of state patient attorneys

Other

Please describe Other

How did you hear about us?*

Referral

Facebook

Postal Mail

Email Newsletter

Online Search (Google, Bing, Yahoo, etc)

Convention

Seminar

Webinar

Other

Please describe Other

Setup your account

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Email*

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Consent*

I agree to the PIMadeEasy privacy policy and Terms of use.*

You must agree to our policies and terms of use in order to create a new account. It may take several seconds to process after clicking the register button. Please be patient. You will be directed to a new page when the process is complete.