Online Application

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PERSONAL DATA: PRACTICE DATA: INSURANCE DATA:
Your Name:

Practice Name:

Claims are handled by:
Inhouse staff
Billing Co

Claims are filed electronically:
Yes
No

What is your average turn around on insurance claims?
15-30 days
30-60 days
60-90 days
Over 90 days
E-Mail Address:
Number of Providers in the practice:
1
2
3-5
6 or more		 Approx. % of unpaid claims due to filing errors?
5%
10%
15%
20% or more
Phone Number: 

Best time to contact you:
Active Patient Count:
New Practice
100-500
500-1000
1000-1500
Over 1500		 Approximate Percentage of claims uncollectable?
5%
10%
15%
20% or more
Business Contact Person:

Phone Number:
Approximate number of patients seen per month:
New Practice
50-100
200-500
600 or more		 Approximate number of claims processed weekly:
50
100
200
250 or more
Mailing Address:
Number of employees used for administrative support:
1-2 people
3-5 people
5-10 people
Over 10		 Is your present method for billing insurance companies?
Satisfactory
Needs Work
Unsatisfactory

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EAG Medical Billing Solutions
Post Office Box 1304
Brownwood, TX 76801
Phone (915) 641-9171  E-Mail: webmaster



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