Skip to content
ABOUT
ABOUT
MEET THE OWNER
RECOMMENDATIONS
NEWS
PRODUCTS
PRODUCTS
PATIENT TESTIMONIALS
DEVICES (MedicaldeviceUSA.com)
CONTACT
PRACTICE ANALYSIS FORM
csqadmin1
2021-10-26T15:10:49-07:00
PRACTICE ANALYSIS FORM
Legal Practice Nam
(Required)
Practice Type
Primary Practice Owner Name
(Required)
Office Manager Name
(Required)
Physician Name
(Required)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
State Sales Tax %
Multiple Locations:
Yes
No
If Yes, Where
Owner Cell:
(Required)
Manager Cell
(Required)
Physician Cell
(Required)
Years in Business:
(Required)
Website
(Required)
Number of Patients in Database
Number of Pt’s seen per week
How many Pt’s do you want to convert per month?
Pt’s Age Demographics?
Staffing
Medical Director
Yes
No
Experienced Injector
Yes
No
Marketing Team
Yes
No
Who handles case mgmt./presenting finances in your clinic
How many Mid-Level Providers are in your Clinic
Do you want help w/ Practice Management & Developing in Office Systems?
Yes
No
What type of physician designations are within the practice?
PRODUCTS & INTEREST
Are you using Regenerative Medicine?
(Required)
Yes
No
If Yes, what type
Are you using Skin Graft?
(Required)
Yes
No
If Yes, what type
Are you using Membrane Patch?
(Required)
Yes
No
If Yes, what type
What are the Regenerative & Biologics Medicine you are using today
Cash Pay
Insurance Reimbursable
Do you have a current Q Code being used for Reimbursement?
Yes
No
If Yes, Q code #?
Are you using Hyaluronic Acid?
Yes
No
If Yes, what type?
Initials:
MARKETING
To better serve the marketing needs of our physicians, we have brought on a new digital marketing company. To assess how these services might benefit your practice, please complete the following:
1. What Marketing have you done in the past?
2. Do you have a monthly budget for marketing?
Yes
Not at this time
Not sure
If Yes, our current budget is
3. How many locations do you have? (Please list)
4. Are you currently doing any digital marketing?
No
Yes
if “Yes” please list below 5.
5. What is the biggest headache or keeping you up at night with your practice?
6. How many clients/patients are you able to handle a month and for what procedures?
7. What procedures/services do you offer and/or want to promote via digital marketing?
What services are you looking for? (check all that apply)
Marketing Consulting
Digital Marketing
Website Development / Design
PPC/SEM/Lead Generation
SEO
Mobile Development
Media Buying
Local and OnPage
Other Media Buying
Specify Media Buying Below
10. What current type of Imaging Device(s) do you carry in office today?
Billing
What current Billing Software are you using today?
Do you utilize a Third Party Billing Service?
Yes
No
If Yes, Name?
Will you need a 3rd Party Billing or Credentialing Expert?
Yes
No
Will you need a 3rd Party VOB or Pre-Authorization Expert?
Yes
No
What Commercial Insurance are you in Network with today?
(Required)
What Clearinghouse are you using today?
Group Medicare PTAN?
Yes
No
DME PTAN?
Yes
No
PTAN in Process?
Yes
No
Do you have PTAN for the provider & have the benefits been reassigned to the group?:
Yes
no
What will you be Billing under
Supervising Provider
Mid-Level Provider
Any Specific Thoughts or Requirements
PAYOR MIX (% of patients per payor)
Medicare
(Required)
Medicaid
(Required)
Commercial
(Required)
Cash
(Required)
Other
(Required)
Providers List
PROVIDER NAME
CREDENTIALS
BOARD CERTIFIED: yes or no
SPECIALTY
EMAIL:
CELL PHONE
Add
Remove
If Multiple Owners, please list all names here
Primary Practice Owner
Email
Date
MM slash DD slash YYYY
Initials
Go to Top
