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51
Questions
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1
Practice Legal Name
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2
Years in Operation
Please Select
0-1
2-5
6-10
10+
Please Select
Please Select
0-1
2-5
6-10
10+
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3
Total Number of Providers (PTs, PTAs, interns)
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4
Number of Admin Staff
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5
Number of Locations
Please Select
1
2
3-5
6+
Please Select
Please Select
1
2
3-5
6+
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6
Name
First Name
Last Name
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7
Email
example@example.com
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8
Phone Number
Area Code
Phone Number
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9
Preferred Communication
Please Select
Email
Phone
Text
Portal
Please Select
Please Select
Email
Phone
Text
Portal
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10
Select all services that apply to your practice:
Orthopedic
Sports Rehabilitation
Aquatic
Neuro
Pediatrics
Pelvic Floor
Other
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11
Telehealth Offered?
YES
NO
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12
Do you sell/rent any of the following equipment?
Braces
TENS
Exercise Bands
Other
We do not sell/rent any equipment
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13
Do you accept walk-ins/urgent appointments?
YES
NO
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14
What are your weekday hours of operation?
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15
What are your weekend hours of operation?
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16
Average new patients per week
Please Select
0-10
11-25
26-40
40+
Please Select
Please Select
0-10
11-25
26-40
40+
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17
Average new patients per day
Please Select
0-10
11-20
21-40
40+
Please Select
Please Select
0-10
11-20
21-40
40+
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18
Age groups served
Pediatric
Adults
Senior Citizens
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19
Languages spoken
English
Spanish
French
Other
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20
Require bilingual VA support?
YES
NO
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21
Scheduling/EMR system
Please Select
Athenahealth
WebPT
eClinicalWorks
DrChrono
Kareo/Tebra
Simplepractice
Other
Please Select
Please Select
Athenahealth
WebPT
eClinicalWorks
DrChrono
Kareo/Tebra
Simplepractice
Other
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22
Appointment booking methods
Online
Phone
Self-check in
Other
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23
Appointment types
Evaluations
Follow-ups
Group
Telehealth
Other
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24
Eval length
Please Select
30mins
45mins
60mins
61+mins
Please Select
Please Select
30mins
45mins
60mins
61+mins
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25
Treatment length
Please Select
15mins
30mins
45mins
60mins
61+mins
Please Select
Please Select
15mins
30mins
45mins
60mins
61+mins
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26
Waitlist length
Please Select
No waitlist
1-2 weeks
3-4 weeks
1 month+
Please Select
Please Select
No waitlist
1-2 weeks
3-4 weeks
1 month+
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27
No-show/Cancellation policy
Please Select
24hrs
48hrs
Same day
Other
Please Select
Please Select
24hrs
48hrs
Same day
Other
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28
Do you want the VA to handle reminders?
YES
NO
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29
Do you accept insurance?
YES
NO
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30
If you answered yes above, check all payers that apply:
Medicare
Medicaid
BCBS
Aetna
Cigna
United Healthcare
Other
We do not accept insurance
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31
Do you need insurance verification support?
YES
NO
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32
Do you accept cash-pay/self-pay patients?
YES
NO
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33
Copay collection
Please Select
At check-in
After visit
Billed later
Other
Please Select
Please Select
At check-in
After visit
Billed later
Other
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34
Need a VA to help with claims follow-up/denials?
YES
NO
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35
Current EMR
Please Select
Athenahealth
WebPT
SimplePractice
Kareo/Tebra
eClinicalWorks
Other
Please Select
Please Select
Athenahealth
WebPT
SimplePractice
Kareo/Tebra
eClinicalWorks
Other
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36
Documentation support needed:
Admin tasks only
Scribe/documentation assistance
Both
Neither
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37
Do you have standardized templates?
YES
NO
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38
Do you require SOAP format?
YES
NO
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39
Documentation turnaround
Please Select
48hrs
Next day
Same day (additional fees may apply)
Please Select
Please Select
48hrs
Next day
Same day (additional fees may apply)
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40
Patient communication methods
Phone
Email
Text
Portal
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41
Would you like a VA to handle incoming calls?
YES
NO
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42
Do you receive physician referrals?
YES
NO
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43
If you answered yes to referrals, please select how they are processed:
Fax
Portal
Email
Other
Not Applicable
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44
Do you need support with medical records requests?
YES
NO
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45
How does your team communicate internally?
Slack
Teams
Email
EMR Portal
Other
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46
Do you require a HIPAA BAA
YES
NO
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47
List any other systems that our team will need access to:
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48
List any additional compliance needs/requirements:
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49
Select your MAIN area of concern:
Scheduling
Billing
Documentation
Patient Communication
Referrals
Insurance Verification
Calls
Appointment Reminders
Email Management
Other
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50
Define success in 90 days
Please Select
Reduced admin workload
Faster billing turnaround
Fewer no-shows
Better patient satisfaction
Other
Please Select
Please Select
Reduced admin workload
Faster billing turnaround
Fewer no-shows
Better patient satisfaction
Other
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51
Anything else we should know?
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