Billing Intake Form

Name *

Email address *

What is your current professional role?

What state are you practicing in?

How did you hear about therassistant?

What is your estimated annual revenue?

What types of insurance do you accept?

Please select at least one option.

Medicare

Medicaid

Private insurance

Self-pay

What are your primary billing challenges?

Please select at least one option.

Claim denials

Delayed payments

Patient collections

Insurance verification

What software do you currently use for billing?

What is your preferred method of communication?

What is the average number of patients you bill per week?

Do you require assistance with coding?

Are you currently using any billing service?

Which service or services are you interested in?

Please select at least one option.

BILLING SERVICES

CONSULTING SESSIONS

CREDENTIALING SERVICES

If yes, please specify the name of the billing service.