CONSULTATION INTAKE FORM

Please provide the following information and answer the questions below.

(Last)

(First)

Business Address

(City)

(State)

(Zip)

Business Name:

Work phone

Cell phone

Email

example@example.com

Work Website:

Current Status with panels

In-Network: (list all)Out of Network

In-Network Panels

Please list all insurances you are currently in-network

Current Systems

EHRPaper charting

EHR NAME:

Billing:

NoneHave a billerUse ClearinghouseUse EHR

Accounting System: (Rectifying Accounts)

EHRPaper tracking/ExcelOnline AccountingOther

Name of Online Accounting Program:

I understand that I am paying for business consultation services with Katia Callan, owner of Insight Wellness of Maryland. This service is meant to assist you in developing a system that works best for you. No method is perfect, it might take trial and error to develop an appropriate system based on your practice, number of hours you work, and based on your current skill level. Consultation services are tailored to you. If something isn't working, it is up to you to express concerns regarding our work together.

Current Consultation Agreement Fee Structure

$250 per hour

Continual Consultation Plans

$600 for 3-hour block - Initial Credentialing Plan or Billing Plan$850 for 4-hour block - Jumping Point: Initial Start-Up Plan$1100 for 5-hour as need block - On-Call Consultation

I understand the following disclaimer: When accepting consulting services we can make no guarantees in terms of the following: acceptance on panels, acceptance or rejection of claims, or payments by insurance companies. These are all based on a contract between you and them. Assistance and assessment of this can be made during continued consultation services.

Signature

Date

Business Associate Agreement Coverage: This form also acts as a necessary BAA between: (TYPE BUSINESS NAME BELOW) and Katia Callan of Insight Wellness of Maryland. This covers the viewing and assessment of protected information covered by HIPAA for assessing, reviewing, and submission of billing claims. This will remain in effect until (ENTER DATE BELOW)

Business Name:

Date:

Recommend for 1 year from date of initial contract.

Signature

Date

1615 York Road, Suite 300 Lutherville, MD 21093

phone 443-470-9297 - fax 800-785-3951

katia@insightmaryland.com www.insightmaryland.com