Academy Consultation Services Request Form

Complete the form below and an Academy representative will respond shortly. Thank you!

1. Name of your practice or business *This question is required.

2. Your name *This question is required.

3. Your title *This question is required.

4. Your email address *This question is required.

5. Your phone number

6. What kind of consulting services do you or your practice require? *This question is required.

Chart Audit
Coding Education
Practice Management
Other - Write In Please enter an 'other' value for this selection.

7. Briefly describe the issues you'd like to address. *This question is required.

8.
Are you or any of your staff currently members of the American Academy of Ophthalmology or the American Academy of Ophthalmic Executives (AAOE)? *This question is required.

9.
If "Yes", please provide the full name and/or member number of the ranking Member.

10. Have you used other ophthalmic coding or practice management consultants in the past?

11. How did you hear about Academy consultation services?