Missing Lincs Billing Questionnaire

Name

First NameLast Name
Company Name
Name of Business
E-mail
example@example.com
Phone Number
Address of Practice

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your relationship to the practice?
Owner, Office Manager
What is the best day and time to call you back?
Mondays between 12pm-3pm
Practice Technology

This section is to provide us with information about your current technology within the practice as it relates to billing.
Are you currently Outsourcing your billing?
If you are currently using software, what brand are you using?
Example: ChiroTouch, ChiroSpring, ChiroSpring360, SimplePractice, etc.
Are you open to switching software providers?
Is your software Cloud based?
How many computers do you have within your office?
How many of those computers are being used regularly?
If the software is not cloud based a remote session will need to be established to perform billing duties.
Are you using the latest version of Windows 10 in the clinic?
Which clearinghouse are you currently using?
Infinedi, TriZetto/Gateway, Availity, Office Ally
Insurance and Billing

This section will provide information about your billing needs.
How many licensed health professionals are in the practice that require billing services?
If the practice accepts Medicare, are the providers Par or Non-Par?

ParNon-ParNot Participating
Which insurance companies is the practice in-network with?
Example: BCBS, Medicare, Medicaid, UHC, PH, Advantage plans
Does the practice accept Auto or Worker's Compensation patients?
# of Total Insurance Claims Billed per Month:
Monthly Dollar Amount of Insurance Services Collected ($):
Total dollar amount received from insurance approximate
Monthly Dollar Amount of Medicare/Medicaid/VA Claims Collected Per Month ($):
Total dollar amount approximate
Monthly # of New Patients:
Practice Statistics

This section is about your practice volume
Monthly New Patients?
Monthly Patient Visits?
Estimated Accounts Receivable (AR) Balance:
0-121+ days from service date
If you need to make a change to your current billing department and are considering Missing Lincs, How soon would you need our services?

ASAP1-3 Months3-6 Months
How did you hear about us?
Do you have any additional questions or concerns?
All information provided in response to this form will be used for the limited purpose of intake and consultation by Missing Lincs Billing LLC, and to gather necessary information to create a file in the event you choose to enroll in our services.

PLEASE NOTE: COMPLETING THIS FORM DOES NOT BY ITSELF CONSTITUTE A CONSULTATION OR CREATE A CLIENT BILLING RELATIONSHIP WITH MISSING LINCS BILLING LLC OR ITS OWNER.
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Practice Technology

Insurance and Billing

Practice Statistics