Free Analysis

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So that we may prepare a customized analysis for your practice, please complete the following questions to the best of your ability.

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CONTACT INFORMATION:

Name:
Title:
Practice Name:
Specialty:
Phone Number:
Address:
City:
State:
Zip:
Email:
SERVICES OF INTEREST: (Check all that apply)	Billing Service A/R Reduction Provider Credentialing Consulting New Practice Set-Up
BILLING SERVICE/AR REDUCTION
Number of Providers:
Number of Office Locations:

Charges:
Collections:
PRACTICE PAYOR MIX (fill in %):
Medicare %:
Medicaid %:
HMO %:
Commercial %:
BCBS %:
Workers Comp %:
No-Fault %:
No Insurance/Cash %:
PARTICIPATING PROVIDER WITH (Check all that apply):	Medicare Medicaid BCBS HMOs Worker's Compensation
Average # of Patients treated per day:
Average Charge per Treatment:
Average # of Claims sent per Month:
Average # of Procedure Codes per claim:
Average # of Statements mailed per Month:
Average Current Charges per Month:
Average Current Collections per month:
# of Current backlog of Claims (45days)
Current A/R Balance:
How are charges and payments currently being posted?:	Billing Service Internal Practice Software via EMR via Internet Manual Process
Name Of Software Used:
Name Of EMR Used:
Would you be interested in implementing an EMR in your practice?	Yes No OTHER (Type Below)

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 (Type Below)

PROVIDER CREDENTIALING:
Please list the Insurances/MHOs that you are interested in:
CONSULTING:
Please describe your consulting project:
How did you hear about PCMG?:
Questions/Comments: