MPS - Client Evaluation Form

Medical Practice Solutions

	1. General Information
Legal Name of Practice (*)	Please type your full name.
d/b/a (*)	Invalid Input
	Address
Street (*)	Invalid Input
PO Box	Invalid Input
City (*)	Invalid Input
Zip Code (*)	Invalid Input
Telephone (*)	Invalid Input
Fax	Invalid Input
E-mail (*)	Invalid email address.
Name/Title Principal Contacts (*)	Invalid Input
	2. Practice Information
Location(s) of Practice (*)	Invalid Input
Type of Practice (Specialties) (*)	Invalid Input
Number of Physicians (*)	Invalid Input
Number of PA’s (*)	Invalid Input
Number of Nurse Practitioners (*)	Invalid Input
	3. Billing Information
Internal or External Billing Service (*)	Invalid Input
	If External
Name of Billing Service	Invalid Input
Renewal Date (if any)	Invalid Input
Any Notice Required: No/Yes	Invalid Input
Current Rate/Payment	Invalid Input
Who does Encounter Entry	Invalid Input
Number of Encounters per Year	Invalid Input
Total Charges per Year	Invalid Input
Total Receipts per Year	Invalid Input
	4. Accounts Receivable
Over 120 - $ (*)	Invalid Input
90 - 120 - $ (*)	Invalid Input
60 - 90 - $ (*)	Invalid Input
30 - 60 - $ (*)	Invalid Input
	5. Insurance Information
What insurance carriers are you currently contracted with? (*)	Invalid Input
Do you have a high percentage of patients with Medicare? (*)	yesno Invalid Input
Do you have a high percentage of patients that are self pay? (*)	yesno Invalid Input
	6. Software
What is your current software program? (*)	Invalid Input
Can it be accessed remotely? (*)	yesno Invalid Input
	7. General Questions
What is your reason for obtaining a quote from Medical Practice Solutions? (*)	Invalid Input
What are your expectations of a billing service? (*)	Invalid Input
No Spam Security	Refresh Invalid Input

	Thank You for contacting MPS, we will get back to you ASAP.