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Provider Profile Form

Please complete this online form so that we have a better understanding of your practice.

You may also use the downloadable version; download, print, complete the form, then fax or email it to us.

FAX:  1-866-266-7906
EMAIL:  info@ts4mo.com
Please enter your practice Name:
Please list the specialty/specialties at your practice:
Do you currently use a Practice Management System?
Are your computers currently on a LAN (loca area network)?
Do you currently have high-speed internet access at your practice?
How many insurance claims do you process each month?
Which claims clearinghouse are you currently using?
On average, how long is it taking to receive payment?
What is the most common error for rejected claims?
Please tell us how many of your claims are being transmitted electronically?
What percentage of your claims are:
Medicare:
Medicaid:
BC/BS:
Commercial:
Other:
If there is something special or unique regarding any of your payors, please tell us:
What percentage of claims are returned with errors?
If so, can you provide information regarding your current system? 
What system are you using?  Are you satisfied with your current system? 
What's on your wish list to make your current system better?
YES
NO
Workers Comp:
YES
NO
If you are currently using,have ever used, or have considered using a billing service, please tell us about it:
YES
NO
How many providers does your practice have?
How many locations does your practice have?
Do you have more than 1 (one) TAX ID?  If YES, how many, and a brief explanation.
Is there anything else we should know about your practice?
Contact Information:
*Please re-enter your email for confirmation:
*Email:
*Name:
*Contact Phone:
How did you hear about TS4MO?:
* Enter the characters as shown.  Be sure to enter as shown without the spaces using capitalization as necessary.
*Spam Protection:
Required
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I am looking for a billing service because (please check all that apply)
I want to increase revenue
I want to save time
I do NOT like dealing with billing
I want to reduce billing errors
Fields with * are required
I am not happy with our current billing solution.
Other:
Provider Profile in PDF Format for printing
Click HERE for PDF
TS4MO Provider Profile Form
Professional Office Services, Inc
Availity - Claim Management Clearinghouse
Healthwind/Horizon Practice Management
Our Affiliates                                                                                                                   TS4MO  (Technology Solutions 4 the Medical Office)  -  PO Box 2383  -  Renton, WA  98056  -  Copyright © 2006