In order for us to provide a more accurate quote, please print and fax this form to: 609-259-0982

Comprehensive Forms: Print and fax: Practice Information Forms--word

Comprehensive Forms: Print and fax: FORMS--pdf

Brief Form: FORM- word

or mail to: NMBS LLC, 7 Nolan Rd, Allentown, NJ 08501

Comprehensive forms; details:

NetProphets Medical Billing - Practice information Forms Please complete this introductory survey, and fax to our office so we may provide you with a competitive quote.                                 Date: ___________________________

Name of Provider: ___________________________________________

Specialty: _________________________________________________

Name of Practice: ____________________________________________

Address: ___________________________________________________

__________________________________________________________

Phone: _____________________________________________________

Fax Number: _________________________________________________

E-mail address: _______________________________________________Website: ____________________________________________________

How long has the provider been in practice at this location? ________________

Are there other providers working for this practice?
No_____ Yes ______   If yes,
Name/Specialty _______________________________________   Name/Specialty _______________________________________     Name/Specialty _______________________________________     Office Manager: ________________________________________
Office Hours: __________________________________________
Taking New Patients? Yes_______   No_______
Average number of patients per week: _______________Current Dollar Amount on the Practice Accounts Receivables? _________________________AND/ OR: Average collected Receipts monthly? ____________________________________
Average claims per month? __________ Average price per claim? ____________Approximate number of active accounts? _______________________________What is your insurance rejection rate? 0-10%___ 10-20%___ 20-30%_______How many Patient Statements do you send (or plan to send) each month? ______ Approximate Breakdown of Patient Types per week:

Self Pay:____________________________________
Workers' Comp:_______________________________
Auto:_______________________________________
Government:_________________________________
Medicare:___________________________________
Medicaid:___________________________________
Commercial Par:_______________________________
Commercial Non-Par:___________________________
HMO Par:____________________________________
HMO Non-Par:_________________________________
Blue Cross/Blue Shield:__________________________

Does provider collect copays at time of service?__________
Does provider collect deductibles at time of service:_______Number of office staff: ______________
Does Staff work accounts receivables? _______________
Does Staff submit claims? _________________________
If no, who does: _________________________________
Does Provider bill self pay patients? __________________
If not, who does? ________________________________
How do self pay patients pay? _________________________________________________
Approximate number of mail returns per week? ___________
Does provider bill secondary insurance carriers? ___________

Does provider use a collection agency for delinquent accounts? ___________
If Yes, Name of Agency: _______________________________
Percentage Amount Collection Agency Invoices: _________
How old is the account when sent to the collection agency? ___________________

Does Provider Have Contracts any HMO? Yes___ No___
If Yes, which?
________________________________________________________________________________________________________________________________________________

Contracts with Non-HMO Carriers?
Yes: ______ No: _______ If Yes, which ones?
________________________________________________________________________________________________________________________________________________
Is provider Capitated with any Carriers? Yes___ No___
If yes, which ones? ________________________________________________________________________

Does Provider have contracts that have timely filing limits of 120 days or less?Yes ____ No_____
_______________________________________________________________________

Does Provider use Lockbox? Yes____ No____
If Yes, Name of Bank: _______________________________________________________________________

Does Provider have financial Plan: Yes____ No_____

Does provider have “Assignment of Benefits” form? Yes____ No____
If Yes, is form signed by patient/guardian at time of service? _____________

Does provider have Time Payment Plans? Yes____ No____
Does Provider have compliance plan? Yes____ No_____
When was fee schedule last updated? ______________
When was Superbill Updated? ____________________Does the provider send claims electronically? __________
Which clearinghouse is currently being used: ___________

Is provider affiliated with a hospital(s)? Yes____ No____
If yes, Name(s) of Hospital: ________________________________________________________________________

How many computers are being used in the practice? ____

Are the computers networked? Yes_____No_________Do your computers have internet access? Yes____No____

What Internet method are you currently using? Dial up ____ DSL____ Cable____What is the highest broadband speed available? DSL_____ Cable_____
Are the computers: Owned_____ Leased______ ?What type of computers are they? ________________________________________________________________________
________________________________________________________________________

Does the provider have a scanner? Yes____ No____

please check off the services below which you anticipate needing:

·        Office set up
       Emdeon clearinghouse registration and major carrier notification
       Lytec 2008, practice database set up
       Network evaluation
       Customized superbill set up with code and fee analysis
       Front desk workstation set up
       Start Up Practice
· Core Service
       Patient Information data entry
       Charge Entry
       Claim Editing & Electronic submission
       Payment Posting
       ERA/EFT
       Secondary Paper claims
       Denial follow up; appeals; calls
       Accounts receivable review
       Weekly, monthly, customized reports
       Weekly Mailer for superbills/encounters
       Unlimited Fax of superbills/encounters
       Email addresses for staff
       Online support & training
· Additional Services
   Lytec Scheduler (included with System Hosting clients)
   Patient Statement Billing(three cycle)
   Past Due/Delinquest Collection
   Data Migration from Lytec program
Data Migration from non Lytec program
Provider Enrollment
Provider credentialing
ICD-9 or CPT coding assistance
In office staff training (number of staff members_)
Other, please specify_______________________