Potential Client Data Questionnaire

1
Your Full Name* This field is required.
First Name
Last Name
2
Your E-mail* This field is required.
example@example.com
3
Phone Number* This field is required.BEST number to reach you
Please enter a valid phone number.
4
EMS Business Name* This field is required.As filed with CMS / Medicare
5
DBA (if applicable)
6
National Provider Identifier (NPI)* This field is required.
7
Years in Business* This field is required.
1 year or less
2 - 5 years
6 - 10 years
10 years +
8
EMS Physical location* This field is required.to identify locality with CMS
9
Type of Service* This field is required.
Municipality (City)
County
Hospital
Fire Department (paid)
Private
Volunteer
10
County Serviced* This field is required.
11
Type of License with Texas DSHS* This field is required.
Basic Life Support (BLS)
BLS with Advanced Life Support (ALS) capability
BLS with Mobile Intensive Care Unit (MICU) capability
Advanced Life Support (ALS)
ALS with MICU capability
12
Number of Ambulances in Use* This field is required.
13
Number of Monthly Transports* This field is required.
14
Type of Transports* This field is required.
911 only
Transfer only
911 & Transfer
Other
15
If a Transfer Service, how many "repeat" patients do you transport monthly?Pertains to Medicare patients needing PCS forms
None
1 - 5
6 - 10
10 +
16
If a Transfer Service, how many non-emergency Medicaid patients do you transport monthly?Pertains to Medicaid patients needing PAN
None
1 - 5
6 - 10
10 +
17
Do you offer Wheelchair Services?* This field is required.
YESNO
18
How is Agency's Fiscal Year Reported?
October 1 - September 30
January 1 - December 31
19
How do you prefer Agency's accounting period Reports?Pertaining to end-of-year report creation
Fiscal Year / October - September
Fiscal Year / January - December
Fiscal Year / BOTH reporting types
20
What is your Payer Mix?* This field is required.Identified as a percentage (%) outcome should equal 100%
MEDICARE including HMOs
MEDICAID including HMOs
Commercial/Private Insurance
Self-Pay/Non-Insured
Contracts (nursing homes/hospitals)
Auto/PIP
Other Governmental
21
What were your annual gross charges last year?* This field is required.If completing this form during 4th QTR, use last 12 months data
22
What were your annual contractual allowance adjustments for last year?* This field is required.Amounts Medicare & Medicaid disallow; Carriers you may be contracted with If completing this form during 4th QTR, use last 12 months data
23
What were your total payments last year?* This field is required.If completing this form during 4th QTR, use last 12 months data
24
When did you last update your service Fee Schedule?* This field is required.
25
How do you Document your Services?* This field is required.
Paper
Electronic software
26
Please specify ePCR Vendor
27
How are Agency's RCM Services currently handled?
In-house Billing
Billing Company
Not billing yet
28
What is the method currently used to Route/Send Billing information?* This field is required.
ePCR interface
FTP site
Vendor portal
Fax copies
Mail copies
Unknown
29
What is the method currently used to Route/Send Payment information?* This field is required.including correspondence, EOBs, reconciliations
Agency owned Lockbox
Billing Company owned Lockbox
Billing Company Portal
Fax copies
Mail copies
Unknown
30
Does your Agency require any of the following Procurement Processes?* This field is required.Select all that are applicable
RFQ - request for quote
RFP - request for proposal
Board of Directors Vote
City Council &/or City Manager Vote
Informal quote &/or proposal - I am the Decision Maker
31
What is your Agency's Current Time-frame?* This field is required.As it pertains to possible contract initiation
Immediately
30 - 60 days
60 - 90 days
Checking out my options
32
If Currently Under Contract, What is Agency's Cancellation Notification?* This field is required.Time period to send written notification to current billing company vendor
30 day notice
60 day notice
90 day notice
More than 90 day notice
No notice required
33
What is your level of satisfaction with your current vendor?
Excellent
Good
Fair
Poor
Choose not to answer
34
Are there any specific services you are wanting/looking for?Services that are either not available or just not offered
YESNO
35
Please specify service(s)
36
How did you hear about us?* This field is required.
Please Select
Please Select
Postcard
Personal Visit
Exhibit Hall Attendee
Referral
Internet Search
Should be Empty: