New Client Intake Form

New Client Intake Form

Thank you for your interest in working with Medical Billing with Portia! Please complete this intake form so we can assess your needs and determine if we’re the right fit to help your practice thrive. We’ll review your responses and reach out within 48 business hours.
1️⃣ Practice Information
Practice Name
Contact Name
Title/Role
Email
example@example.com
Phone Number
Please enter a valid phone number.
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2️⃣ About Your Practice
Website & Social Media Links (if any)
Specialty (e.g., Family Medicine, Cardiology)
Number of Providers
Number of Staff (front-end & back-end)
3️⃣ Current Billing Process
How is your billing currently handled?

Fully outsourced to a billing companyFully in-houseHybrid (some in-house, some outsourced)Not sure
What EHR/Billing software do you currently use?
Do you have documented Standard Operating Procedures (SOPs)?
4️⃣ Pain Points & Goals
What are the top 3 challenges you’re experiencing with your current revenue cycle?
What goals would you like to accomplish by working with us?
Type a question

YesNoOther
5️⃣ Alignment Check
Are you open to implementing biblical principles and integrity-based strategies in your business?
What is your desired timeline to start working with us?
What is your approximate budget for consulting & training?
6️⃣ Additional Notes
Is there anything else we should know about your practice, team, or goals?
Should be Empty:

New Client Intake Form

1️⃣ Practice Information

2️⃣ About Your Practice

3️⃣ Current Billing Process

4️⃣ Pain Points & Goals

5️⃣ Alignment Check

6️⃣ Additional Notes