Provider/Group Name: Provider/Group Speciality: Your Full Name: Address: City: State: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip: Email Address: Phone Number: Fax Number: Best Time to Contact: Mornings Afternoon Evenings Weekends Current Billing: Billing In-House Billing is Outsourced No Billing Services Yet How many providers are in your practice? Physicians (Full Time) Physicians (Part Time) Physicians Assistants Nurse Practitioners Are you planning on adding any providers in the coming six months? YesNo Are you a Medicare participating provider? YesNo Do you accept Medicaid? YesNo How many offices do you have including your main office? How many patients do you see weekly between all providers? How many days a week do you practice medicine? How many managed care plans are you contracted with? How many capitated insurance plans are you contracted with? On a monthly basis, how many: Commercial claims are processed? Medicare claims are processed? Medicaid claims are processed? Patient statements are sent out? What is the practice's insurance make-up? (Based on dollars billed) Medicare: % Medicaid: % Blue Shield: % Commercial: % HMO Contracts: % No Insurance: % What were your gross billings for the following calendar years? (Gross billing are the amount billed before contractual adjustment are made) Previous Year: Current Year: What were your net receipts for the following calendar years? (Net receipts are the actual collections) Previous Year: Current Year: Other questions or comments:

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