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Practice
Information
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| Your Name: First: |
* Last
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| Practice Name (if dif.): |
(Optional) |
| Address: |
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| City: |
State
Zip
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| E-Mail: |
* Phone
Ext.
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Do you have a website?
Yes
No |
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If so, please enter it here: |
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Type of Practice (e.g.: surgery, anesthesia,
OB, mental health, etc.): |
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Number of Practitioners |
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Volume
& Income Information, and Billing Preferences
When giving the information for volume and income,
please only consider claims and income for which
you will want us to do the billing.
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Volume (claims per week)
Please enter the approxmiate number of claims
you will want us to bill per week
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Income
We need to know the average dollars per claim,
the average gross income per week, or the average
gross income per year.
Please select one of the following: |
Average dollars received per claim. Please enter
amount collected, including co-pay. Not amount
billed.
Average gross income received per week
Average gross income per year
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Services
Number
of $ indicate how expensive each service is.
Please check off the services you would like
us to include in your quote.
Note: you will have the opportunity to see how
different choices effect your quote on the next
page. |
Bill out all insurance claims, and follow up
on any unpaid or denied claims
Keep track of authorizations/prior approvals
and notify you when they are running out $
Perform insurance verifications prior to first
visit $$$
Track amounts owed by patients and mail bills
to them $$
Take phone calls from patients to discuss balance
or insurance questions $$
Take phone calls from various practitioners
in your group to answer billing questions $
Manage deposits for your practice $$$
Will you require specialized or unusual reports?
$
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| Note: we
also offer coding and practice consultation
services. These are priced separately. |
Additional Information |
| How did you hear about us? |
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| I would like to start |
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| Currently my billing is handled by: |
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| I am looking for a billing service
because (please check all that apply): |
I want to increase revenue
I want to save time
I hate dealing with billing
I want to reduce billing errors
I am unhappy with our current biller
Other
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| Do you have any other questions
or comments? |
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As mentioned above, we will never
contact you without your permission, or share
your information with anyone.
Please check one or more boxes below: |
Please call me
Please e-mail me
Please send me a brochure
Please put me on your mailing list to receive
notification of future speical offers and discounts.
Please send me a start-up packet. (Checking
this box gives us permission to contact you.)
Please do not contact me at this time. |
If you would like us to contact you, please
make sure the contact information above is correct.
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Your Full Service Billing Partner
Call us toll free at (800) 811 1882 Ext. 2201
or email info@usemedibill.com |
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