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  Office Profile
Do you Submit any insurance claims electronically?*

What software are you currently using?*

Who prepares your claims?

Timeline to receive payment

Do you submit Secondary Claims*

Do you bill on a HCFA 1500*

What other forms

Do you generally have claims that need to be resubmitted*

Carrier Problems*

Do you have an Outstanding account's receivable?*

Approax Balance

No. of Providers

Is there more than one office location?*


No. of office staff

No. of patients seen a day

No. of active accounts

No. of Blue Cross Blue Shields claims

No. of Commercial claims

No. of Medicare claims

No. of Medicaid claims

No. of H M O claims

Are you the Primary Care Physician?*

No. of workers comp claims

No. of personal inquiry claims

Monthly average amount of claims $

How many Procedures per visit / per claims

How many patient statements do you prepare per month

Who prepares?

If you were to purchase medical billing software, how many workstations would you need

Name of Practice

Phone No.


Prepared by



Yes or No *

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