We appreciate your interest in being a mentor. Please provide contact info and select those areas in which you think you could provide guidance and expertise as a mentor to your peers. (Offering to be a mentor does not imply that the physician seeking advice should not obtain their own legal and/or practice management counsel.)

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1. Please provide your name:

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2. What is your specialty or specialties?

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3. Please provide your practice name or employer and your role:

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5. Please provide the best number to ensure your peer(s) can reach you

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6. Which of the following is your preferred initial contact method?

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7. Professional & Personal Development

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8. Practice or Employment Models & Challenges

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9. Insurance & Payment Challenges

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10. Private Practice Operations

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11. Patient Care

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12. Revenue Enhancement

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13. Any other areas in which you are interested in being a mentor which were not included?

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