Prospective Client Information

Prospective Client Information
We are excited and happy to have you as a potential new Reliant Practice LLC client and are looking forward to working with you and your team for many years to come. This Worksheet is designed to help you to provide to us the necessary information about your practice that will allow us to produce a proposal for services. You can choose to email the completed form directly to us, or if you prefer to fax the completed form, our fax number is (919) 706-1439. If you have any questions about this form, please feel free to email or call us at 919-948- 7009.
CLIENT CONTACT INFORMATION:
PRACTICE NAME:
PRACTICE (PRIMARY) ADDRESS:
MAIN PHONE NUMBER:*
OFFICE FAX NUMBER:
PRACTICE CONTACT NAME:
CONTACT EMAIL ADDRESS:
example@example.com
CONTACT PHONE NUMBER:
BILLING CONTACT NAME:
BILLING CONTACT EMAIL:
example@example.com
BILLING CONTACT PHONE NUMBER:
QUESTIONS ABOUT YOUR PRACTICE:
1. Legal Practice Name:
2. Practice Website Address:
3. Number of Physical Office Locations
4. Offsite Facilities – Do your providers see clients outside of the office – perhaps in a community-based setting, or via TeleHealth?
5. Number of Full Time Providers:
6. Number of Part Time Providers:
7. Average Number of billable clients per week, including self-pay:
a. Per Full time provider:
b. Per Part time provider:
8. Average Number of Insurance Claims to be Filed Per Week:
a. Per Full Time provider:
b. Per Part time provider:
9. Do you currently have a practice management system (PM)? If so, what is the name of the system?
10. Do you currently have an electronic health record (EHR)? If so, what is the name of the system?
11. Do you currently use an outside billing service?
12. Who is your current Clearinghouse?
13. If you were to sign for billing services, what is the timeframe for commencement of services?
14. What are the most important services or qualities that you are looking for in a service provider?
15. How did you find out about Reliant Practice, LLC, and is there someone we should thank for a referral?
Should be Empty:

Prospective Client Information

CLIENT CONTACT INFORMATION:

QUESTIONS ABOUT YOUR PRACTICE: