Address 1:
|
|
Address 2:
|
| City/Town:
State:
Zip: |
|
Telephone:
email:
|
Specialty:
|
|
Number of Providers:
|
|
Contact Person:
|
| 1. Number of Active
Patients: |
|
| 2. Total number claims
per month: |
% Medicare
% Commercial
% HMO/Managed Care
% Medicaid/W.C., PI
% Other
|
| 3. What percentage
of all claims are rejected: |
|
| 4. What is the average
dollar amount of a claim? |
|
| 5. Do you currently
submit electronic claims? |
|
| 6. Would you like
further information on: |
|
|
Briefly describe
the nature of the problem you would like assistance with and
any comments:
Thank you for
your inquiry. A Peak Healthcare Solutions representative
will be in touch with you regarding your confidential medical
services quote.
|
|
|
