Group Name:

Doctors Name:

Contact Name:

Address:

Phone Number:

Fax Number:

Reps Name*

Reps Address*

Reps Phone*

Reps Fax*

Reps Mobile Phone*

Reps Other Phone*

Number of Patients per month

Average hourly wage of office personnel

Cost of envelopes and stamps @ .40 per invoice

Number of offices

Number of Billed Patients per month

Master Card / Visa rate

Average amount charged per transaction

Total amount charged each month

Statement fees

Number of checks monthly

Amount of NSF checks

Time to prepare deposit slips & bank runs

Avg. no. of days to receive payment on claims

Amount of claims outstanding over 14 days

Average time spent verifying insurance
(AMA National Avg. is 30 min.)

What is your claims rejection rate?
(AMA national avg. 25%)

Average time it takes per patient

Are claims processed electronically? Yes or No

Internally or outsourced. Cost of outsourced claims

Number of Claims per month
(Including phone calls and follow-up)

Time to prepare one claim

Cost of envelopes and stamps @ .40 per invoice