Free Analysis -

Free Analysis

* Indicates required field

Name: *

First

Last

Specialty: *

Practice Name: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

SERVICES OF INTEREST: (Check all that apply) *

Billing Service Provider Credentialing Consulting New Practice Set-Up

BILLING SERVICE

Number Of Providers: *

Number of Office Locations: *

Average Monthly Collections: *

Average # of Patients treated per day/week/month: *

PRACTICE PAYOR MIX (fill in %):

Medicare %: *

Medicaid %: *

HMO %: *

Commercial %: *

BCBS %: *

Workers Comp %: *

No-Fault %: *

No Insurance/Cash %: *

# of Current backlog of Claims (if known) *

Current A/R Balance (if known): *

How are charges and payments currently being posted?: *

Name Of Billing Software Used: *

Name Of EMR Used (if different): *

Are you interested in implementing an EHR in your practice? *

Yes No Other

Why are you considering a billing service? *

Cannot find qualified staff/key individual left Do not want to invest in software/hardware/upgrades Present staff/service not sufficent Know outsourcing is wise decision Other

Comment *

PROVIDER CREDENTIALING:

Please list the Insurance Payers that you are interested in:

Payers: *

CONSULTING:

Please describe your consulting project:

Comment *

How did you hear about PCMG?: *

Questions/Comments: *

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