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


 

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