| List your Top Four Complaints Regarding Billing/Collections |
| Complaint 1: |
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| Complaint 2: |
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| Complaint 3: |
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| Complaint 4: |
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| Do you currently use the internet to access medical information? |
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| Do you send your claims to Arbitration? |
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| Do you analize your EOB's? |
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| Do you pursue claims through Fair Hearings? |
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| Do you use a Billing Service? |
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| Number of Monthly Electronic Claims Proceessed: |
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| Number of Monthly Paper Claims Processed: |
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| Do you track your denied claims due to coding errors?: |
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| Do you track claims lost by the carrier?: |
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| How much do you spend on staff resources to process your claims?: |
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| When was the last time you updated your fee schedule?: |
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| Which areas do you see the need to improve in your practice?: |
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| Thank you for taking our survey. |
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If you would like someone from our office to contact you regarding our services, please
indicate Yes or No |
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| Practice Information |
| Your Name |
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| Practice Name |
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| Address |
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| Telephone |
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| Business/Office Manager |
| Name |
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| Number of Physicians: |
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| Number of Office Locations: |
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| Number of Employees: |
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| Patient Information |
| Number of Patients Seen Daily: |
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| Number of New Patients Monthly: |
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| Other Information |
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