Reliable Medical Claim Services Inc

Practice Profile / Application

What is your legal practice name?
Is your practice a corporation? Yes No
If "Yes", please select the state of incorporation below.
State of Incorporation
What is your practice specialty?
When was your practice established? / MM / DD YYYY
Federal Tax ID
How long have you been in your current location?
Web Site
Provide location information:
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Fax - (###) - ### ####
Email
Provide the physician names and license numbers, and key personnel info:
Physician First Last
License Number
Physician First Last
License Number
Physician First Last
License Number
Physician First Last
License Number
Office Manager First Last
Contact Number - (###) - ### ####
Key Contact First Last
Contact Number - (###) - ### ####
Bank Information:
Name
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Do you work off a Super-Bill? Yes No
Other?
What is your average dollar amount billed on a monthly basis? $ . Dollars Cents
What are your average monthly receivables? $ . Dollars Cents
What are your practice business hours?
How many patients do you see each day?
Are all patients treated at the location named above? If not, where are these patients treated?
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Tell us about your current billing service:
In-House Yes
What software are you using?
Version
Which clearing house do you use?
Outsourced Yes
How long have you used your current biller?
What is the timeframe for your billing service change?

Days
Months
Tell us about your current billing process:
What are your current billing issues/concerns?
What is your idea of a perfect billing company?
What do you expect from your Reliable Billing Solution (check as many as appropriate): 1 Time Billing Entry 1 Time posting of EOBs Daily billing entry Posting of EOB’s to patient accounts Monthly patient statements Monthly practice analysis reporting Electronic claim filing Monthly deposit reporting Paper claim filing Monthly aging reporting Appeals written and processed promptly Calls to aging accounts (soft collections) 800 number for patient billing inquiries Extensive Follow-up 800 number for written communication A plan for uncollected receivables No VRU; real people answering phones Posting of EOB’s to patient accounts Seasoned billers processing your claims Streamlined billing solutions A business office extension to your practice UPS funding for document sharing A customized billing solution tailored to your practice needs and ability Consultative team approach A Reliable Billing Solution
How many doctors or NPP’s are in your practice?
Physicians
Physicians Assistant
Nurse Practitioners
Physical Therapists
Other
Who are your major insurance companies you contract with? And what is the mix percentage?
Aetna
%
Blue Cross
%
Blue Shield
%
Medicare
%
Medicaid
%
Private
%
Workers Comp
%
Other
%
If yes, what are the parameters of your contract? Please enter below.
Do you have any capitation agreements? Yes No
Monthly payout contract $ . Dollars Cents
Maximum number of visits monthly
Any limitations?
Has anything changed with your practice within the past 6-12 months?
Change in location? Yes No
New contracts executed? Yes No
Change in patient load? Yes No
Change in biller? Yes No
Other?
Describe any additional information or requirements for your Reliable Medical Billing Solution.

Provide location information:

Provide the physician names and license numbers, and key personnel info:

Bank Information:

Tell us about your current billing service:

How many doctors or NPP’s are in your practice?

Who are your major insurance companies you contract with? And what is the mix percentage?

Has anything changed with your practice within the past 6-12 months?