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Below are some basic questions to fill out about the person filling out this form. All Form Fields in Blue & Bold represent a required area to complete the form.

 
Your Name  
Title/Position  
Contact Phone Number  
Email Address  

 

Below are basic questions to fill out about your practice. All Form Fields in Blue & Bold represent a required area to complete the form.

 
Practice Name  
Address of Practice  
City, State, & Zip Code  
Practice Phone Number  
Website Address  
Practice Specialty  
If Other, Please List here  
Number of Physicians  
Head Physician Name  
Physician's Contact  
Office Manager  
Office Manager Contact  
Number of Personnel  
Comments on Manager, Physicians, or Personnel  

 

Below are basic questions to fill out about your practice. All information is strictly confidential between submitting party and PFMS. To view confidentiality statement, click here.

 

Approximate number of patients?

    

Please Fill out the following questions below to the best of your ability.
 

YES

 NO ???

Do you experience a lot of rejected claims?

If Yes, Percentage?

Do you currently have a backlog of claims?
Do you use and Outside Service to process claims?

Name of Outside Service

     

Are you satisfied with this service?
Do you find filing claims time consuming?
Would you like to reduce turn around time for reimbursement?
Would you consider an outside billing source?

 

How many patients seen per week?

    

Average number of claims per month?

    

Average billed per claim?

    

Number of staff working on claims?

   

Biggest problem you or your staff are

currently experiencing in your office?

 

 

Below are basic questions to fill out about your practice. All Form Fields in Blue & Bold represent a required area to complete the form.

 

   

YES

 NO ???
Practice has some sort of Compliance Program In Place?

How would you rate your compliance coverage?

Coverage for federal/state/local laws & rules

If you do not have a compliance program, are you aware of the laws & agencies enforcing federal, state and local rules, policies and standards?

Would you be interested in having a compliance program for your practice?

Additional Information on this can be found in the Programs Section
Do you have a process for retrieving delinquent (slow-pay) patients before sending to collections?
If No, would you be interested in slow-pay account follow up services?

Additional Information on this can be found in the Programs Section
Would you like PFMS to contact you about further inquiry?  

If Yes, how would you like PFMS to contact you?

Information is from Part A of the Form

 
Additional Comments or Questions

 

 

  
     

 

 

 
 

PFMS Mission Statement

Physicians Financial & Management Services is a "client-centered" company dedicated to providing medical providers and healthcare organizations the finest billing, patients accounts receivable management and reimbursement outsource services available.

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We focus on helping Medical Practices improve the bottom line, by applying six essential qualities: accuracy, promptness, courtesy, knowledge, professionalism and technology.

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