New Provider Questionnaire Form Practice Name Name * First Name Last Name Email * Phone * (###) ### #### Specialty * Number of Providers * Year of Formation: Most used CPT codes * How many patients do you see a day? * 1-5 6-10 11-15 16+ How many patients do you see per week? * 1-10 11-20 21-30 31-40 40-50 50+ Are you currently using a billing service or billing in-house? * Yes No Which billing software do you use? * What are you most pleased with in your current billing services? (if applicable) What are you least pleased with? (if applicable) Which insurance companies are you currently contracted with? Please list all. * Are you interested in getting contracted with other companies? * Yes No Maybe Do you currently use EMR (Electronic Medical Records) software in your practice? * Do you currently receive EFT payments and ERA’s (Electronic Remittance Advice)? If not, are you interested in receiving EFT payments and ERA’s? Yes No Maybe What are your average monthly charges? * $ What is your average percentage of collections? * Approximately how many dollars do you have on your aging sheet over 60 days? * $ Approximately how many dollars do you have on your aging sheet over 90 days? * $ What services are you looking to receive from your biller? Billing Credentialling Accounts Receivable Clean Up Consulting Thank you!
