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Remote Services Client Intake Form
Please complete the following so we can get a better understand of your practice needs and how we can help. After this form is completed, we will send over a proposal.
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* Indicates required question
Practice Name
*
Your answer
Practice Address
*
Your answer
Practice Phone
*
Your answer
Practice Email
*
Your answer
Doctors Name (if multiple, please list all)
*
Your answer
What practice management system do you use?
*
Your answer
What are you seeking to gain from our financial/insurance support?
*
Your answer
Average number of new patient exams per month
*
Your answer
Average number of starts per month:
*
Your answer
Number of Active Patient Accounts In Good Standing
*
Your answer
Number of Active Patient Accounts Past Due
*
Your answer
Number of Active Insurance Accounts In Good Standing
*
Your answer
Number of Active Insurance Accounts Past Due
*
Your answer
Have you made any business changes recently? (ie; new tax ID, address change, etc)
Your answer
Please list all insurance companies your office is contracted with
*
Your answer
Do you accept medi-caid?
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Yes
No
Do you accept assignment on insurance?
*
Yes, on both primary and secondary
Yes on primary only.
No.
Do you bill for records? If so, at what point (ie: exam, separate records appt)
*
Your answer
Are you a Mari's List Member?
*
Yes
No
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