Practice Intake Form
Practice Name
*
Practice Type
*
Please Select
Private Practice
Group Practice
Specialty
Multi-Specialty
Urgent Care
Hospital
Laboratory
Other
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
*
Number of Insurances Accepted
*
EHR/EMR System
*
Please Select
EPIC
Athena
eClinicalWorks
Kareo
Other
Billing
*
Please Select
In-house
Outsourced
Hybrid
Data Range Request
*
Please Select
Review of last 30 days
Review of last 60 days
Review of last 90 days
Review and Monthly Services
I'm not sure
Area of concern: (select all that apply)
*
ALL
Medicare
Medicaid
Coding Accuracy
Aging AR
Client Bill
Credentialing
Self-Pay
High Denial Rate
Delayed Reimbursement
Patient Bill Assistance
Insurance Guidelines
Education and Training
Eligibility Verification
Unknown Revenue Loss
Workflow Inefficiencies
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
Date
Signature
Submit
Submit
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