Fees for Billing Services Proposal Form

Practice Name

Tax ID#

Main Contact Person

Phone Number

- -

Street

City

State

Zip Code

Practice Website

Monthly Charges

Gross Monthly Receipts (based on past 12-month average)

# of Office Visits (12-Month Average)

Current Total Accounts Receivable

Aged Accounts Receivable 120+ days

Medical Specialty/Specialties

Number of Providers

Number of Locations

Hospital Services Provided?

Yes

No

Surgical Services Provided?

Yes

No

If yes, type of surgeries:

Current Billing Software/System/Billing Service

Using EHR?

Yes

No

If yes, name of EHR

Are you currently utilizing electronic claims?

Yes

No

Are you currently utilizing eligibility verification?

Yes

No

Are you currently utilizing electronic remittance?

Yes

No

If yes, please provide vendor name and services used

Number of patient statments sent per month

Does your practice take credit cards?

Yes - in office

Yes - billing service

No

If yes, which credit cards are accepted?

Do you utilize a collection agency for delinquent payers?

Yes

No

If yes, what collection agency do you work with?

What are the main carriers you are contracted with? Please include the approximate % of total claims.

Most frequently used CPTs:

CPTs

Please list TOP 10 MOST COMMON DXs:

DXs

Do any of your procedures require medical records to be sent with a charge?

Yes

No

If yes, how would we receive medical records from your office?

For Mental Health Providers/Groups ONLY - Please Complete Below

Do you currently bill under a group NPI or as individuals?

Individuals

Group

Is your organization State Certified?

Yes

No

Are there any other special considerations you feel need to be addressed in a proposal?

Yes

No

If yes, please describe: