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  info@proclaiminc.com

  1-800-937-4245

ProClaim Inc., 157 Main Street, PO Box 32, Andover, NH 03216

Practice Start-Up Sheet

Thank you for contacting ProClaim Inc. So that we may prepare for our upcoming appointment, we ask that you please complete the following questions about your practice to the best of your ability.

Practice Name * Specialty* No. of Providers* Year of Formation Select One 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Email* Phone*   Fax*     Best time to contact you     Date Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Date 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2006 2007 Time Select Time 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM How is your billing currently being done Select One Manually Computer Billing Service Other 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. Procedure Code Fee Frequency (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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