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Request Information
Thank you for your interest in PaySpan Health for healthcare payment automation. Please take a few minutes to complete the form below so that someone from Payformance Health can contact you to discuss your healthcare payment automation needs in greater detail. 
Required fields are indicated by (*).
Contact Information
First Name(*)
 Last Name(*)
Company(*)
Address(*)
City(*)
 State(*)
 Zip(*)
Phone Number (*)
Email Address (*)

Type of Organization
 Healthcare Payer

  Healthcare Provider
Question/Comment:
Healthcare Payer Interest Area (Optional)
What payment needs do you have?
 (Please check all that interest you....)
 Distribute Electronic Fund Transfers (EFTs)
  Printing and delivery of EOPs
  Automated Provider enrollment
   Distribute Electronic Remittance Advices (ERAs)
  Distribute HIPAA 835 compliant payment and remittance advices
  Printing and delivery of EOBs
  Other
Healthcare Provider Interest Area (Optional)
What payment receipt needs do you have?
 (Please check all that interest you....)
 Receive EFTs
  Flexible formats to match PMS system
  Online enrollment with Payers
  Reprint remittance advices
   Receive ERAs
  Receive HIPAA 835 compliant payment and remittance advices
  Other
Healthcare Payer Organization Profile (Optional)

Tell us more about your organization?  (Please answer all that apply....)

How many members does your organization cover?
How many Providers are in your network?
How many claims do you process on an annual basis?
How many payments do you process on an annual basis?
How many EOPs do you send in a year?
How many member-based EOBs do you send annually?
How large is your organization by annual revenue?

 

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