Genesis Assist - Request for Services

1
What Service(s) Are You Requesting?* This field is required.
Billing
Insurance Panel Credentialing
Consulting
2
Name* This field is required.
First Name
Last Name
3
Email
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Practice Information
Practice Name
Practice Website
6
Practice Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Do you have a Group NPI / Tax ID established?* This field is required.
YESNO
8
Are You Credentialing Under a Group NPI or Individual NPI?* This field is required.
Group NPI
Individual NPI
Not Sure
9
List the State(s) Do You Want to be Credentialed In?* This field is required.
10
List the Insurance Panels You Want Credentialing For* This field is required.
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Ok
Ok
11
Is Your CAQH Profile Up to Date?* This field is required.
Yes
No
Do Not Have CAQH Set-up
12
Are You Interested in Genesis Assist Helping with CAQH Yearly Maintenance?* This field is required.
YESNO
13
Are You Currently Credentialed Under Any Other Group Practice?* This field is required.
YESNO
14
List any other special circumstances related to credentialing or demographic updates that you need assistance with?
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Ok
15
How Many Years Has Your Practice Been in Business?* This field is required.
16
How Many Providers are on your Clinical Team & What Types of License Do They Have?* This field is required.
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Ok
17
In General, Do Your Providers Work Full-Time or Part-Time?* This field is required.
Mostly Full-time
Mostly Part-time
Mix of Full and Part-time
18
Briefly Describe Your Plans to Grow Your Practice* This field is required.
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Ok
Ok
19
Do You Currently Have Any Administrative Staff?* This field is required.
YESNO
20
Which Insurance Panels, if any, are you Currently Credentialed With?* This field is required.
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Ok
21
How Do You (or did you) Handle Billing?* This field is required.
In-House
Third-party Biller or Agency
No Billing Yet
22
What is the Name of the Third-Party Biller You Used or Are Using?* This field is required.
23
What is the Name of the EHR You Are Using?* This field is required.
24
What Are the Pain Points With Your Current Billing Situation?* This field is required.
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Ok
25
What are Your Average Monthly Receipts?* This field is required.
26
What Challenges or Opportunities are You Facing?* This field is required.
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Ok
27
How did you hear about Genesis Assist?* This field is required.
Web Search (e.g., Google)
Referral by a Genesis Assist Client
EHR Provider
AACC Conference
Other
28
Please let us know if you have any questions or other information you want us to know.
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Ok
29
By submitting this form, you agree to receive text and/or email messages at your phone number from Genesis Assist. Consent is not a condition of any services. You have the right to stop or cancel at any time. Msg frequency varies. Msg & data rates may apply.
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