Physician's Name

Address:

City:

State:

Zip Code:

KS AL AR AZ CA CO CT DE FL GA IA ID IL IN KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT WA WI WV WY VA

Phone #

E-Mail Address

Do you experience rejected claims?

  Yes No

What percentage of all claims are rejected (Medicare, Medicaid, Commercial)

  0%-10% 10%-20% 20%-30% More than 30%

How does your office process claims?

  Manual Electronic

If electronic; Are you processing:

Medicare

  Yes No

Commercial Carriers

  Yes No

What percentage of claims are Medicare?

  0%-10% 10%-30% 30%-60% More than 60%

If you are processing claims manually:

Do you use a computer to generate forms?

  Yes No

Do you fill in claims manually?

  Yes No

Do you use an outside service to process claims?

  Yes No

Are you satisfied with this service?

  Yes No

Do you find filing insurance claims time consuming?

  Yes No

Would you like to reduce the turn around time on insurance payments?

  Yes No

Would you consider an outside service for processing claims electronically?

  Yes No

Is your software compliant to HIPAA standards?

  Yes No