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
Work Comp
Non-Contract FFS
Self Pay

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

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