Date: Practice’s Name: Address: City: State: Zip:       Specialty: Phone: Fax: e-mail: WebSite:     1 Number of Doctors Please describe each doctor below:   Sr. No. Provider’s Name How long Practicing Work how many days/week # of patients seen weekly 1         2         3         4         5           2 How many employees do you have? Please describe your staff bellow:     Sr. No. Provider’s Name How long Practicing Work how many days/week # of patients seen weekly 1         2         3         4         5         6         7         8         9           3 Does any provider perform surgery? No Yes How many per week?     4 Type of facility Hospital Inpatient-21 Hospital Outpatient-22 Emergency Room-23 Ambulatory Surgery-24 Skilled Nursing Facility-31 ursing Facility-32 Custodial Care Facility-33 Office - 11 Rehabilitation Facility (Outpat.)-62 Rehabilitation Facility (Inpat.)-61 Home Visits - 12 Other:   5 Are you in Network with how many insurances?   6 How are the doctors billed out? under your practice group Under their own # Other     7 How are you currently billing? In house Outsourcing   8 Monthly charged amount (average) $   9   Monthly collected amount (average): Insurance Pymt $   Front Desk Pymt $   10 Monthly insurance adjustment amount (average) $   11 Medical Software package that you are currently using: Name: Version number: