Burrock Billing &

                   Management Services

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 FREE ANALYSIS

Please take a moment to answer these questions. The information you provide will help us evaluate your current situation and determine how to help you increase your efficiency and improve your cash flow. We will contact you after we have reviewed your information.

RED = required field
1. How many claims (electronic & paper) do you
submit per month?
  1-50
 50-150
 150-300
 300-500
500-1000
 1000+
2. Do you currently submit claims electronically?
  Yes
No
3. If yes:
 

What billing software do you use?

What clearinghouse do you use?
4. Who performs your billing now?
  In-house staff
 Billing service
 Combination of the two
5. What is the approximate percentage of the following patient insurance and payment sources?
  % Medicare/Medicaid
 % Champus/Tricare/ChampVA
 % Auto
 % Worker’s Comp
 % Commercial/HMO/PPO
 % Self Pay
6. Are you interested in computerized scheduling?
  Yes
 No

7. What is the greatest billing problem you are currently experiencing?
 

8. What services are you looking for? Check all that apply:
  Claims Only Billing
 Full Practice Billing
 Follow-Up Only
Deposits
 Verification of Benefits
 Credentialing
 Code & Fee Analysis
 Customized Reports
 Superbill Design
 Old A/R Cleanup
 Provider & Office Staff Training
 Assistance With Office Forms &  Organizational Tools
 Programs to Increase Cash Flow
 General Compliance (OIG)
 HIPAA Information & Compliance
 Technology Assistance
 Computer Networking

9. Practice Information:
 

Practice Name:

Practice Specialty:

Number of Providers:

Number of Office Locations:

City/Town of Each Office Location:

Approximate Total Number of Patients:

Average Number of Patients Seen Each Day:

Average Amount Per Claim:

10. Contact Information:
  Contact Name:

How Do You Wish To Be Contacted?
(select a method and enter the info)
Phone
Email required
Mail