Medical Billing Questionnaire

Contact Name^*

Email^*

Address^*

City^*

State^*

Zip Code^*

Main Contact Phone^*

Number of Patient Visits (aka Encounters) per Month^*

Type of Organization^*

Monthly Receipts^*

Current Month Receipts^*

12 Month Rolling Average^*

Specialty^*

Check all that apply

How much Out of Network Billing (OON) do you process monthly $$$ ? of claims?

Please enter a specific numerical value, or tool will not work (eg. 0, 1, 10, 100)

Number of Providers / MDs^*

Number of mid-level providers (ie. non-MDs)^*

Number of Offices^*

Primary State in which your Practice Operates^*

Please select the specific billing service model you are most interested in: Please check one or more

1.What EHR/PM software solution they are using?
2.What Billing Software?
3.Are you currently outsourcing to a billing company?
4.What areas do you need help within your billing Department?
-Augmentation of Staff : Please explain
-Add remote resources for one or more areas: Please Explain
5.Why are you considering a change or addition to your current RCM/billing solution? Please explain
6.What is your biggest concern with your current process? Please explain
7.Do you currently bill in house?

If Yes : Please explain your current staffing level and areas of concern.

Medical Billing Services Questionnaire