<% Function SendMail(strfrom,strto,cc,bcc,subject,body,component) component=UCase(component) format=UCase(format) Select case component Case "CDO": Set mobj=Server.CreateObject("CDO.Message") mobj.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/sendusing")=1 mobj.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/smtpserver")="localhost" mobj.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/smtpserverpickupdirectory")="C:\Inetpub\mailroot\Pickup" mobj.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport")=25 mobj.Configuration.Fields.Update mobj.From=strfrom mobj.ReplyTo=strfrom mobj.To=strto mobj.Subject=subject mobj.HTMLbody=body mobj.Cc=cc mobj.Bcc=bcc mobj.Send Set mobj=Nothing Case "CDONTS": Set mobj=Server.CreateObject("CDONTS.NewMail") mobj.From=strfrom mobj.To=strto mobj.Value("Reply-To")=strfrom mobj.Subject=subject mobj.body=body mobj.MailFormat = 0 mobj.BodyFormat = 0 mobj.Cc=cc mobj.Bcc=bcc mobj.Send Set mobj=Nothing End Select End Function '---------------------------------- %> <% function TestCaptcha(byval valSession, byval valCaptcha) dim tmpSession valSession = Trim(valSession) valCaptcha = Trim(valCaptcha) if (valSession = vbNullString) or (valCaptcha = vbNullString) then TestCaptcha = false else tmpSession = valSession valSession = Trim(Session(valSession)) Session(tmpSession) = vbNullString if valSession = vbNullString then TestCaptcha = false else valCaptcha = Replace(valCaptcha,"i","I") if StrComp(valSession,valCaptcha,1) = 0 then TestCaptcha = true else TestCaptcha = false end if end if end if end function %> <% action=Request("action") if Request.ServerVariables("REQUEST_METHOD") = "POST" then if TestCaptcha("ASPCAPTCHA", Request.Form("captchacode")) then bdy="
"& _ "New comments:
"& _ "Date: "& now & _ "
"& _ "

"& _ "Company Name: "& Request("company_name") &"
" & _ "Name: "& Request("name") &"
" & _ "Email: "& Request("email") &"
" & _ "Phone: "& Request("phone2") &"
" & _ "Fax: "& Request("fax") &"
" & _ "Name of Practice: "& Request("practice") &"
" & _ "Contact Name: "& Request("contact_name3") &"
" & _ "Best Time to Contact:: "& Request("contact_time") &"
" & _ "Contact Phone: "& Request("contact_phone") &"
" & _ "Specialty Type: "& Request("specialty") &"
" & _ "Address #1 "& Request("address1") &"
" & _ "Address #2: "& Request("address2") &"
" & _ "City: "& Request("city") &"
" & _ "State: "& Request("state") &"
" & _ "Zip Code: "& Request("zip") &"
" & _ "Comments:

"& Request("comments") &"

"& _ "We Have an: " & Request("billing") &"
" & _ "File Claims Electronically: " & Request("fileelec") &"
" & _ "Number of Providers in Practice: " & Request("numberofproviders") &"
" & _ "Approximate number of patients seen per month: " & Request("numberofpatients") &"
" & _ "Weekly cost of In-House Staff: "& Request("costofstaff") &"
" & _ "Monthly cost of Billing Service: "& Request("costofbilling") &"
" & _ "What is your average turnaround on insurance claims? " & Request("insturnaround") &"
" & _ "Approximate percentage of unpaid claims due to filing errors: " & Request("percentofunpaid") &"
" & _ "Approximate percentage of claims uncollectable: " & Request("claimsuncollectable") &"
" & _ "Average Value per claim: "& Request("claimvalue") &"
" & _ "How do you feel about your present method for billing? " & Request("satisfaction") &"
" & _ "

"& _ "
" Sender=Request.Form("email") Recepient="jenniferpare@midvtmedicalbilling.com" SendMail Sender,Recepient,"","","Mid VT Medical Billing Contact Us Form",(bdy),"cdo" ErrMsg="Your information has been sent successfully.
" else ErrMsg="Image verification did not pass, please try again.
" end if end if %> Mid VT Medical Billing - Free Evaluation  
 
 
 
<%=ErrMsg%>

 

Fields Marked With * Are Required

Personal Information :

*Name:



Name of Practice:


Address #1
:

*Email:




Contact Name:

Address #2:

*Phone:




Best Time to Contact:


City:


Fax:




Contact Phone:


State:

  Specialty Type:
Zip Code:

Comments:


Practice Information :

We have an:
In-house Staff
Billing Company


 




File Claims Electronically:
yes
no




Number of Providers in Practice:
1
2
3-5
6 or more

Approximate number of patients seen per month:
50-100
100-200
200-500
500 or more

Current Cost of Billing:

Weekly cost of In-House Staff:



Monthly cost of Billing Service:
 

Insurance Information:

What is your average turnaround on insurance claims?
15-30 days
30-60 days
60-90 days
Over 90 days




Approximate percentage of unpaid claims due to filing errors:
5%
10%
15%
Over 20%




Approximate percentage of claims uncollectable:
5%
10%
15%
Over 20%


Average Value per claim:




How do you feel about your present method for billing?
Satisfactory
Needs Improvement
Unsatisfactory


 

CASE SENSITIVE
Image Verification:

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