Care A Lot Medical, LLC
Practice Analysis
PRACTICE NAME
PRACTICE OR GROUP NAME
FULL NAME OF THE PERSON COMPLETING THE FORM
First Name
Last Name
CONTACT PERSON PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
INDIVIDUAL AND/OR ORGANIZATION NPI
INDIVIDUAL OR ORGANIZATION EIN
CAQH ID
ORGANIZATION ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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ORGANIZATION PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
EMAIL
example@example.com
PLEASE PROVIDE A LIST OF CONTRACTED INSURANCE
WHAT IS THE PROVIDER GROSS ANNUAL INCOME?
PLEASE SEND US A COPY OF THE REPORT
WHAT IS THE PROVIDER GROSS MONTHLY INCOME?
PLEASE SEND US A COPY OF THE REPORT
ARE YOU CONTRACTED WITH MEDICARE ?
Please Select
YES
NO
DO YOU OWE MEDICARE?
Please Select
YES
NO
ARE YOU CONTRACTED WITH MEDICAID?
Please Select
YES
NO
DO YOU OWE MEDICAID?
Please Select
YES
NO
THE NAME OF YOUR EMR/EHR SOFTWARE?
HOW ARE CLAIMS BEING SUBMITTED?
Please Select
ELECTRONIC
PAPER
WHAT MOTIVATED YOU TO GET IN TOUCH WITH US ?
Please feel free to contact us directly at info@carealotmedical.com. We look foward to hearing from you.
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