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Legal Business Name

Practice Name

# of Providers (F.T.E.)

Provider Name(s)

Service Location Address

Billing Address (if different)

Phone

Fax


How many claims do you currently process per month?

What are your average Billables, per month?

Have you ever been denied In-Network status by any Carrier?
What are your average Receivables, per month?

Of your total Receivables, what percent is Current (60 days or less)?

Of your total Receivables, what percent is over 120 days old?
How many FTE's (Full-Time Equivalents) do you employ to execute the Billing function?

What is the name of your current Practice Management Software/Billing Software?