OutSource Medical Data Services Provider Practice Analysis Form

P. O. Box 871134
Stone Mountain, GA 30087
TEL (770) 469-3018
FAX (770) 498-2333

People don't care how much you know...Until they know
how much you care. Getting you paid is what we do best.

Provider Practice Analysis Form

Practice Group or Name:
Doctor’s Name:
Specialty:
Address:
City:
State:
ZIP Code:	-
Primary Contact:	Position:
Office Phone # Extension - -	FAX # - -
E-mail
Please answer the following questions regarding your practice:
Does your practice perform its own insurance billing?	Yes No
How many Commercial insurance claims do you process each month?
How many Medicare insurance claims do you process each month?
How many Medicaid (CMOs) claims do you process each month?
How many days (30, 45, 60) does it take on an average to receive payment from…	Commercial Carriers Medicare Medicaid
How do you bill patients for balances due?
Does your practice prepare its own patient statements/bills?	Yes No
Does your office perform insurance claim follow-ups and collections?	Yes No	Comments:
What are the total monthly collections? ($ Received)	Commercial Carriers Medicare Medicaid Other
Number of active patients (Patients with a balance due)?
Average number of patients seen?	Daily Weekly Monthly
What is your credit and collections policy?
What is currently owed to the practice by:	Insurances Medicare Patients Medicaid Other
Do you have any old unprocessed and/or rejected claims?	Yes No
Describe the largest problem you are experiencing with your practice:

*Thank You!*