The Kingdom RCM Method™ — Private Client Intake Application

The Kingdom RCM Method™ — Private Client Intake Application

Apply for a custom, high-end partnership with Medical Billing With Portia DBA The Kingdom RCM Method™. Please complete all sections thoroughly. Incomplete applications will not be reviewed.
Practice Information

Tell us about your medical practice.
Practice Name*
Owner/Medical Director Full Name*

First NameLast Name
Email Address*
example@example.com
Direct Phone Number*
Please enter a valid phone number.
Business Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Practice Website*
Years in Business*
Number of Locations*
Entity Type*
Tax ID or NPI*
Provider & Service Overview

Help us understand your team and services.
Number of Providers*
Provider Specialties (list all)*
Average Monthly Patient Volume*
States Where Providers Are Licensed (list all)*
List of Services and Procedures Offered*

Payer Mix Percentages*

	Percentage (%)
Medicare
Medicaid
Commercial
Self-pay

Current Billing Structure

Share your current billing and collections setup.
Which best describes your current billing structure?*

In-houseOutsourcedHybrid
Current EMR/EHR System*
Clearinghouse*
Billing Software*

Accounts Receivable (AR) Balance by Aging Category*

	Amount ($)
0-30 days
31-60 days
61-90 days
91-120 days
Over 120 days

Average Monthly Collections ($)*
Clean Claim Rate (%)*
Denial Rate (%)*
Upload AR Aging Report*

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Upload Recent EOBs *

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Upload Monthly Collections Report *

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Upload Staff Workflow Chart (optional)

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Pain Points & Goals

Share your challenges and aspirations.
Top 3 Revenue Cycle Challenges*
Past Unsuccessful Approaches Tried*
Financial Goals for Next 12 Months*
Describe Your Ideal Revenue Cycle System*
Are you willing to restructure workflows as needed?*

YesNoMaybe, would like to discuss
Are you open to team training and accountability protocols?*

YesNoMaybe, would like to discuss
Leadership Alignment

Tell us about your team and leadership commitment.
Is leadership actively involved in billing oversight?*

YesNoSomewhat
Do you have dedicated front-end and back-end billing staff?*

Yes, bothFront-end onlyBack-end onlyNeither
Preferred Communication Style*
How adaptable is your team to new processes?*

Very adaptableSomewhat adaptableNot very adaptable
Is leadership committed to transparency and accountability?*

YesNo
Investment Readiness

Assess your practice's readiness for a high-touch RCM transformation.
Are you ready to invest in a luxury, high-touch RCM transformation?*

YesNoI need more information
Are you able to make quick and independent decisions regarding this partnership?*

YesNoDepends on other stakeholders
Do you prefer a long-term transformation partnership or short-term support?*

Long-term transformationShort-term supportNot sure yet
Final Statement

Tell us why you're applying.
Why are you choosing The Kingdom RCM Method™ and why now?*
Should be Empty:

The Kingdom RCM Method™ — Private Client Intake Application

Practice Information

Provider & Service Overview

Current Billing Structure

Pain Points & Goals

Leadership Alignment

Investment Readiness

Final Statement