Provider Practice Set-Up Information Form
Note: * Denotes requiring Copy of Form

Date __________________________________________________

Name of Provider __________________________________________________

Specialty __________________________________________________

Date of Birth __________________________________________________

Social Security Number _________________________________________________*

Place of Birth __________________________________________________

Name of Practice __________________________________________________

Address __________________________________________________

__________________________________________________

Phone __________________________________________________

Fax Number __________________________________________________

Beeper Number __________________________________________________

E-mail address __________________________________________________

How long has the provider been in practice at this location? __________________________________________________

Are there other providers working for this practice?

Yes______________________ No:_______________________

If yes, fill out and obtain all information on the other providers.

Office Manager ______________________________________________

Staff Member ______________________________________________

Staff Member ______________________________________________

Staff Member ______________________________________________

Office Hours ______________________________________________

Taking New Patients? Yes___________________ No____________________

Average number of patients per week ______________________________________________

Current Dollar Amount on the practice Accounts Receivables? ______________________________________________

Approximate Breakdown of Patient Types per week:

Self Pay ______________________________________________

Workers' Comp ______________________________________________

Auto ______________________________________________

Government ______________________________________________

Medicare ______________________________________________

Medicaid ______________________________________________

Commercial Par ______________________________________________

Commercial Non-Par ______________________________________________

HMO ______________________________________________

Blue Cross/Blue Shield ______________________________________________

Does provider collect copays at time of service? ______________________________________________

Does provider collect deductibles at time of service ______________________________________________

Does Staff work accounts receivables? ______________________________________________

Does Staff submit claims? ______________________________________________

If no, who does ______________________________________________

Does Provider bill self pay patients? ______________________________________________

If not, who does? ______________________________________________

How do self pay patients pay? _____________________________________________

______________________________________________

Approximate number of mail returns per week? ______________________________________________

Does provider bill secondary insurance carriers? ______________________________________________

Does provider use a collection agency for delinquent accounts? ______________________________________________

If Yes, Name of agency ______________________________________________

Address ______________________________________________

Phone ______________________________________________

Point of Contact ______________________________________________

Percentage Amount Collection Agency Invoices ______________________________________________

How old is the account when sent to the collection agency? ______________________________________________

Approximate number of attorney requests per week? ______________________________________________

Approximate number of W-9 requests per week? ______________________________________________

Approximate number of medical records requests per week? ______________________________________________

Approximate number of information (Narrative, etc.) requests per week? ______________________________________________

Tax ID # ___________________________________________*

CLIA Certificate Number ___________________________________________*

DEA Certificate Number ___________________________________________*

Medical License Number ___________________________________________*

Medical School ____________________________________________

Location ____________________________________________

Date Graduated ___________________________________________*

Internship ____________________________________________

Location ____________________________________________

Date Completed ___________________________________________*

Residency ____________________________________________

Location ____________________________________________

Date Completed ___________________________________________*

Board Certificate ___________________________________________*

ECFMG Certificate (If Foreign Med School Grad) ___________________________________________*

Medicare Number ___________________________________________*

Medicaid Number ___________________________________________*

RailRoad Medicare Number ___________________________________________*

TRICARE Number ___________________________________________*

Blue Cross/Blue Shield Number ___________________________________________*

UPIN ___________________________________________*

Does Provider Have Contracts With HMO? Yes____________________No___________________

If Yes, Which Ones?

____________________________________________

____________________________________________

____________________________________________

(Use Additional Paper if Needed. Obtain Copy of Contract and Fee Schedule.

Does Provider Have Contracts with Non-HMO Carriers? Yes _______________ No _______________

If Yes, Which Ones? _______________________________________________________ _______________________________________________________ _______________________________________________________

If Yes, Obtain Copy of Contract and Fee Schedule.

Is provider Capitated with any Carriers? Yes _______________ No _______________

If so, which ones? _______________________________________________________ _______________________________________________________ _______________________________________________________

Use Additional Paper if Necessary. Obtain Copy of Contract and Capitation Amounts.

Does Provider have contracts that have timely filing limits of 120 days or less? Yes _______________ No _______________

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Use additional paper if necessary. Please obtain copy of contracts.

Does Provider use Lockbox? Yes_______________ No _______________

If Yes:

Name of Bank: ______________________________________________

Address: ______________________________________________

Phone Number: ______________________________________________

Point of Contact: ______________________________________________

Name of Malpractice Insurance Carrier *: _______________________________________________________

Address: _______________________________________________________

Phone Number: _______________________________________________________

Point of Contact: _______________________________________________________

Policy Number: _______________________________________________________

Policy Amounts: _______________________________________________________

Does Provider have financial Plan: Yes _______________ No _______________

If yes, obtain copy.

Does provider have Assignment of Benefits form and is form signed by patient/guardian at time of service? _______________________________________________ _______________________________________________

Does provider have Time Payment Plans? Yes _______________ No _______________.

If yes, Obtain copy of plan.

Does Provider have compliance plan? Yes _______________ No _______________.

If yes, Obtain a copy.

When was fee schedule last updated? _____________________________________________

Obtain copy of fee schedule.

When was Chargemaster/Superbill Updated? ____________________________________________

Obtain a copy.

Is provider affiliated with a hospital? Yes _______________ No _______________

If yes:

Name of Hospital ______________________________________________

Address ______________________________________________

Phone Number ______________________________________________

Point of Contact ______________________________________________

Has provider ever been sanctioned by any carrier, state or federal agency? Yes _______________ No _______________

If yes, have provider write a letter of explanation.

Has provider ever been personally involved in any malpractice lawsuits or judgements? Yes _______________ No _______________

If yes, have provider write a letter of explanation.

Has provider ever been convicted of any crime? Yes _______________ No _______________

If yes, have provider write a letter of explanation.

How many computers are being used in the practice? _______________________________________________________

Are they Networked? Yes _______________ No _______________

If yes, which network? Novell _____________ Windows __________

What operating system is being used? Windows ___________ Unix _____________

What billing software is being used? _______________________________________________________

Does the provider send claims electronically? _______________________________________________________

What clearinghouse is currently being used _______________________________________________________

What is the highest modem speed available? _______________________________________________________

Are the computers owned _______________ leased _______________

What type of computers are they? __________ 386 __________ 486 __________ 586

Does the provider have a scanner? Yes _______________ No _______________

Does the provider have a CD Burner? yes _______________ No _______________

Does the provider have a copy machine? Yes _______________ No _______________

If yes, is it rented___________, leased___________, owned____________

How long does provider keep medical records? _______________________________________________________

What is provider asking you to do? _______________________________________________________ _______________________________________________________ _______________________________________________________

Date	__________________________________________________
Name of Provider	__________________________________________________
Specialty	__________________________________________________
Date of Birth	__________________________________________________
Social Security Number	_________________________________________________*
Place of Birth	__________________________________________________
Name of Practice	__________________________________________________
Address	__________________________________________________
	__________________________________________________
Phone	__________________________________________________
Fax Number	__________________________________________________
Beeper Number	__________________________________________________
E-mail address	__________________________________________________
How long has the provider been in practice at this location?	__________________________________________________

Are there other providers working for this practice?
Yes______________________	No:_______________________

Office Manager	______________________________________________
Staff Member	______________________________________________
Staff Member	______________________________________________
Staff Member	______________________________________________
Office Hours	______________________________________________
Taking New Patients?	Yes___________________ No____________________
Average number of patients per week	______________________________________________
Current Dollar Amount on the practice Accounts Receivables?	______________________________________________
Approximate Breakdown of Patient Types per week:
Self Pay	______________________________________________
Workers' Comp	______________________________________________
Auto	______________________________________________
Government	______________________________________________
Medicare	______________________________________________
Medicaid	______________________________________________
Commercial Par	______________________________________________
Commercial Non-Par	______________________________________________
HMO	______________________________________________
Blue Cross/Blue Shield	______________________________________________
Does provider collect copays at time of service?	______________________________________________
Does provider collect deductibles at time of service	______________________________________________
Does Staff work accounts receivables?	______________________________________________
Does Staff submit claims?	______________________________________________

If no, who does	______________________________________________
Does Provider bill self pay patients?	______________________________________________
If not, who does?	______________________________________________
How do self pay patients pay?	_____________________________________________
	______________________________________________
Approximate number of mail returns per week?	______________________________________________
Does provider bill secondary insurance carriers?	______________________________________________
Does provider use a collection agency for delinquent accounts?	______________________________________________
If Yes, Name of agency	______________________________________________
Address	______________________________________________
Phone	______________________________________________
Point of Contact	______________________________________________
Percentage Amount Collection Agency Invoices	______________________________________________
How old is the account when sent to the collection agency?	______________________________________________
Approximate number of attorney requests per week?	______________________________________________
Approximate number of W-9 requests per week?	______________________________________________
Approximate number of medical records requests per week?	______________________________________________
Approximate number of information (Narrative, etc.) requests per week?	______________________________________________

Tax ID #	___________________________________________*
CLIA Certificate Number	___________________________________________*
DEA Certificate Number	___________________________________________*
Medical License Number	___________________________________________*
Medical School	____________________________________________
Location	____________________________________________
Date Graduated	___________________________________________*
Internship	____________________________________________
Location	____________________________________________
Date Completed	___________________________________________*
Residency	____________________________________________
Location	____________________________________________
Date Completed	___________________________________________*
Board Certificate	___________________________________________*
ECFMG Certificate (If Foreign Med School Grad)	___________________________________________*
Medicare Number	___________________________________________*
Medicaid Number	___________________________________________*
RailRoad Medicare Number	___________________________________________*
TRICARE Number	___________________________________________*
Blue Cross/Blue Shield Number	___________________________________________*
UPIN	___________________________________________*
Does Provider Have Contracts With HMO?	Yes____________________No___________________
If Yes, Which Ones?
	____________________________________________
	____________________________________________
	____________________________________________

Does Provider Have Contracts with Non-HMO Carriers?	Yes _______________ No _______________
If Yes, Which Ones?	_______________________________________________________ _______________________________________________________ _______________________________________________________

Is provider Capitated with any Carriers?	Yes _______________ No _______________
If so, which ones?	_______________________________________________________ _______________________________________________________ _______________________________________________________

Does Provider have contracts that have timely filing limits of 120 days or less?	Yes _______________ No _______________
____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Does Provider use Lockbox?	Yes_______________ No _______________
If Yes:
Name of Bank:	______________________________________________
Address:	______________________________________________
Phone Number:	______________________________________________
Point of Contact:	______________________________________________

Name of Malpractice Insurance Carrier *:	_______________________________________________________
Address:	_______________________________________________________
Phone Number:	_______________________________________________________
Point of Contact:	_______________________________________________________
Policy Number:	_______________________________________________________
Policy Amounts:	_______________________________________________________

Does Provider have financial Plan:	Yes _______________ No _______________
If yes, obtain copy.

Does provider have Time Payment Plans?	Yes _______________ No _______________.
If yes, Obtain copy of plan.

Does Provider have compliance plan?	Yes _______________ No _______________.
If yes, Obtain a copy.

When was fee schedule last updated?	_____________________________________________
Obtain copy of fee schedule.

When was Chargemaster/Superbill Updated?	____________________________________________
Obtain a copy.

Is provider affiliated with a hospital?	Yes _______________ No _______________
If yes:
Name of Hospital	______________________________________________
Address	______________________________________________
Phone Number	______________________________________________
Point of Contact	______________________________________________

Has provider ever been sanctioned by any carrier, state or federal agency?	Yes _______________ No _______________
If yes, have provider write a letter of explanation.

Has provider ever been personally involved in any malpractice lawsuits or judgements?	Yes _______________ No _______________
If yes, have provider write a letter of explanation.

Has provider ever been convicted of any crime?	Yes _______________ No _______________
If yes, have provider write a letter of explanation.

How many computers are being used in the practice?	_______________________________________________________
Are they Networked?	Yes _______________ No _______________
If yes, which network?	Novell _____________ Windows __________
What operating system is being used?	Windows ___________ Unix _____________
What billing software is being used?	_______________________________________________________
Does the provider send claims electronically?	_______________________________________________________
What clearinghouse is currently being used	_______________________________________________________
What is the highest modem speed available?	_______________________________________________________
Are the computers	owned _______________ leased _______________
What type of computers are they?	__________ 386 __________ 486 __________ 586
Does the provider have a scanner?	Yes _______________ No _______________
Does the provider have a CD Burner?	yes _______________ No _______________
Does the provider have a copy machine?	Yes _______________ No _______________
If yes, is it	rented___________, leased___________, owned____________
How long does provider keep medical records?	_______________________________________________________
What is provider asking you to do?	_______________________________________________________ _______________________________________________________ _______________________________________________________