Practice Legal Name
Primary Contact Person for Billing Matters (Name and Title)
Practice Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Email Address for Billing Communication
example@example.com
Practice Physical Address (Street, City, State, Zip Code)
What is your specialty/primary area of medical practice?
Please Select
Primary Care/Family Medicine
Internal Medicine
Pediatrics
Cardiology
Dermatology
Orthopedics
Obstetrics and Gynecology (OB/GYN)
Gastroenterology
Psychiatry/Mental Health
Chiropractic
Physical Therapy
Other (Please specify below)
If 'Other' specialty, please specify
How many full-time equivalent (FTE) providers/physicians are currently generating claims?
What is the average volume of claims submitted per month?
Please Select
Less than 500
500 - 1,500
1,501 - 3,000
3,001 - 5,000
More than 5,000
Which type of Electronic Health Record (EHR) / Practice Management (PM) system do you currently use?
Epic
Cerner
eClinicalWorks
NextGen
Allscripts
Kareo
Custom/Proprietary System
None (Paper/Manual)
How would you rate your current satisfaction with your existing billing processes (in-house or outsourced)?
1
2
3
4
5
Please indicate which billing services you are most interested in
Full Revenue Cycle Management (RCM)
Claims Submission and Follow-up
Accounts Receivable (A/R) Management and Denial Appeals
Payment Posting and Reconciliation
Credentialing Services
Eligibility Verification
What is the primary motivation for seeking a new medical billing service?
High denial rates
Slow reimbursement times
Staffing limitations/turnover
Need for specialty expertise
Transitioning from in-house to outsourced billing
Starting a new practice
Reducing operational costs
Do you currently accept Medicare/Medicaid patients?
Yes
No
Planning to in the future
Please estimate the percentage breakdown of your payer mix
Rows
0-10%
11-25%
26-50%
51-75%
76-100%
Commercial Insurance (e.g., Aetna, Cigna)
Medicare
Medicaid/Government Plans
Self-Pay/Uninsured
If you wish, upload any recent billing reports or Explanation of Benefits (EOB) summaries for review (Optional).
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Preferred date and time for an initial consultation call
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Any additional comments or specific pain points we should be aware of?
Submit
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