Name
Email
Business Legal Name: DBA / Name Used Publicly:
Address Line 1 Address Line 2
City State/Province ZIP / Postal Code
Billing Address is Same as Business Address YesNo
Business Owned By: Title:
Group NPI: FEIN:
State License Number: Taxonomy Code:
Tentative Billing start date Number of Practice Locations
Address RemoveAdd More
What specialties does your Practice cover? How many Providers are currently active?
Provider Details (Name, Title, and NPI): RemoveAdd More
Do you offer Telehealth or In-person visits, or both? ChooseTelehealth onlyIn-person onlyBoth Telehealth and In-person What is your current patient volume per month?
What is your average Billing / Collections per month? What ICD and CPT codes do you commonly bill?
Name of the Practice Management Software (PMS) Name of the EHR
How are your charts currently being coded? ProvidersIn HouseOutsourced
Do you require coding support from MedVoice? YesNo
How often are claims submitted? ChooseDaily2-3 times/weekWeekly Are you currently experiencing high denial rates? If so, what are the known reasons?
Office contact to request Patient Information/Records
Person who is responsible and can send scanned documents of Payer correspondence on weekly basis and information/records of the Patient as and when needed for AR follow up
Name of the Representative: Phone number of the Representative: Email of the Representative:
RemoveAdd More
Name of the Payer: Activation Date EndDate
Sub Plan - Name of the Payer: RemoveAdd More
Provider IDs for Medicare and Medicaid Provider IDs for Medicare and Medicaid
Name of Clearinghouse: Do you need help with setting up Clearinghouse? YesNo
Top Payer's Name RemoveAdd More
Any ongoing Payer issues?
What is your current average days in A/R?
Are there unpaid or denied claims you'd like us to review? YesNo
Provide details of unpaid or denied claims Please share your last 3 to 6 months A/R report
Do you send Patient Statements currently? YesNo
Do you want us to manage Patient Billing? YesNo
Are Co-pays/Coinsurance collected at check-in? YesNo
Do you offer payment plans? YesNo
Preferred frequency for reports from Medvoice WeeklyBi-weeklyMonthly
Who should receive Reports? (Add email addresses) RemoveAdd More
Individual Provider (Name of the Physician)
Supervising Provider (Name of the Physician)
List of Payers that need to be billed under Individual/Supervising Provider
List of Payers that need the claims to be billed to TPA based on the Provider Contract/Specialty
Admin access to EHR and Practice Management Software to MedVoice TeamClearing House AccessLock Box AccessPortal Access – For all carriers billed.
Additional Notes or Comments Back Save Draft
