Practice Start-Up Sheet

Thank you for your interest in ProClaim Inc. So that we may prepare a quote for you, we ask that you answer the following questions about your practice(s) to the best of your ability.

Practice Name *
Specialty*
No. of Providers*
Year of Formation
Email* Phone*  
Fax*    
Best time to contact you    
Date
 Time
How is your billing currently being done
Why are you contacting us to do your billing?
What is your practice make-up?       
MD/DOs       PAs       NPs  

Other
What is your practice's insurance make-up? (Based on dollars billed)
Worker's Comp
 %
Medicare
 %
Medicaid
 %
Blue Shield
%
Commercial
%
HMO Contracts
%
No Insurance
% (Total Must equal 100%)

Are you a participating provider with Medicare  Blue Shield   HMO's
Please list your most common procedure codes, the fee you charge for each one, and the number of times each procedure was done over the last six months.

(If you can easily print a report with this information,You may fax it to
603-735-6070, instead of re-typing it here.)
Does the practice do any surgical procedures?    No     Yes
If yes, how many per week      What are the average charges
How many patients per day (average) are seen at your office
What is the average patient encounter charge for the practice
Please estimate the number of claims you submit to insurance companies
each month
About how many bills (statements) are sent to patients each month
What are your average billings (charges) per month
What are your average collections (payments) per month
How much money is currently outstanding (receivables)
How did you hear about ProClaim Inc.?

 



For more information, call 1-800-937-4245, ext. 19 or go to our Contact Us page.
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