| Name* |
|
Name
of Practice |
|
| E-mail* |
|
Phone* |
|
| Fax |
|
Best time
to contact: |
|
| Contact
Person* |
|
Contact
Phone* |
|
| Address
#1 |
|
Specialty
Type |
|
| Address
#2 |
|
|
|
| City |
|
|
|
| State |
|
|
|
| Zip
|
|
|
|
|
| |
Practice
Information : |
|
| |
|
Current
Cost of Billing:
|
| |
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 |
|
