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| 6. *Who is your Financial System Vendor? |
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| *What kind of system are you currently running? |
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| *Are you planning on replacing your current system? |
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| 7. Which Medical Records Encoder are you currently using? |
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| 8. Please provide the following contact information: |
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| *Last Name |
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| *Organization |
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| *Street Address |
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| Address (cont.) |
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| *City |
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| *State/Province |
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| *Zip/Postal Code |
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| *Country |
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| *Work Phone |
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| FAX |
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| *E-mail |
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| URL |
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| 9. Please send me email notifications about new Industry Insights. |
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| 10. Would you like to have an Ingenix Sales Representative contact you? |
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| If you selected yes, please select the Ingenix solution(s) that interest you: |
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