Company Name
Email
Contact Name
Phone
Address
Ext:
Fax
City
State
ZIP
Website
Information System:
What information system are you currently using for physician scheduling, billing and collections?
System Name
Billing System
System Version
Scheduling System
Can your information system interface with IDX:
Not Sure
Yes
Yes, We use IDX
Can the system print custom reports?
Not sure
Yes
No
Can the reports be sorted by Diagnosis codes?
Not Sure
Yes
No
Can the reports be sorted by Physician productivity?
Not Sure
Yes
No
Experience:
Does your company have experience with
Hospital Based
specialty programs?
Not Sure
Yes
No
Does your company have experience in Residence Training billing?
Not Sure
Yes
No
Does your company have experience with Charity Care?
Not Sure
Yes
No
Credentialing:
Does your company perform Physician credentialing services?
Not Sure
Yes
No
Claims:
Does your company file claims electronically?
Not Sure
Yes
No
Are your claims filed through a clearing house?
Not Sure
Yes
No
Are your claims filed direct?
Not Sure
Yes
No
Background:
How many full time employees do you have?
1
2
3
4
5
5 to 10
10 to 20
20 to 50
50 to 100
over 100
How long is your company in business?
1 year or less
2 years
3 years
4 years
5 years
5 to 10 years
10 to 20 years
over 20 years
Do you have Spanish speaking employees?
Not Sure
Yes
No
Comments/Questions/References:
(please supply 2 references)
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