Customer Profile Form



Practice Legal Name
Parent Company
Contact Person Name *  
Contact Person Phone *  
Contact Person Email *
Primary & Additional Specialties
Number of Physicians
Number of Verification Employees
PMS System\EMR System
Total number of Annual Claims
Average % Denial Rate (Excluding Eligibility Denials)
Total number of Annual Patient Statements
Total number of Annual Patient Visits\Encouters
Average Price per Patient Statement


Please break down your previous 12 months by the following categories:


Payers Gross Charges Net Revenue
Medicare
Medicaid
Work Comp
Non-Contract FFS
Capitation
Self Pay
DME
Pharmacy
Other

Contracted Payers (EXAMPLES: BCBS, United, Cigna, Humana) Gross Charges Net Revenue



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