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                    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