Practice Intake Form
Practice Name
*
Practice Type
*
Please Select
Insurance-Based
Direct Primary Care- Membership
Direct Primary Care- No Membership
Self-Pay (Non-DPC)
Hybrid Model (Insurance & Membership/Self-Pay Accepted)
Contact Name
*
Contact Phone Number
*
Format: (000) 000-0000.
Contact Email
*
example@example.com
Main Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Offices
*
Number of Providers
*
Billing
*
Please Select
In-house
Outsourced
Hybrid
EHR/EMR System
*
Please Select
EPIC
Athena
DrChrono
eClinicalWorks
Kareo
Elation
Hint Clinical
Cerbo
Atlas.md
AkuteHealth
Other
None
Data Range Request
*
Please Select
Review of last 30 days
Review of last 60 days
Review of last 90 days
Review and Monthly Services
Unsure
What would you like us to assist you with? (select all that apply)
*
ALL
Medicare
Medicaid
Third-Party Insurance Payers
Collections
Self-Pay
Membership Model
Patient Bill Assistance
Insurance Guidelines
Staff Education and Training
Unknown Revenue Metrics/KPI
High Turnover Rate/Employment Advising
Starting My Own Practice
I'm Not Sure
Other
I understand Maison Dexara Inc. does not provide medical or legal advice and/or representation.
*
Yes
No
I understand that results are based on client provided documents. Assessments cannot begin until all documents have been provided by the client. If documents are not provided in a timely manner, results may be delayed.
*
Yes
No
I understand that Maison Dexara Inc. assessment and consultation services do not guarantee claim payment, denial reversal, balance reduction, coverage approval, or any specific financial outcome.
*
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Submit
Should be Empty: