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PRACTICE ANALYSIS FORMcsqadmin12021-10-26T15:10:49-07:00

PRACTICE ANALYSIS FORM

Address
Multiple Locations:

Staffing

Medical Director
Experienced Injector
Marketing Team
Do you want help w/ Practice Management & Developing in Office Systems?

PRODUCTS & INTEREST

Are you using Regenerative Medicine?(Required)
Are you using Skin Graft?(Required)
Are you using Membrane Patch?(Required)
What are the Regenerative & Biologics Medicine you are using today
Do you have a current Q Code being used for Reimbursement?
Are you using Hyaluronic Acid?

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:
2. Do you have a monthly budget for marketing?
4. Are you currently doing any digital marketing?
What services are you looking for? (check all that apply)

Billing

Do you utilize a Third Party Billing Service?
Will you need a 3rd Party Billing or Credentialing Expert?
Will you need a 3rd Party VOB or Pre-Authorization Expert?
Group Medicare PTAN?
DME PTAN?
PTAN in Process?
Do you have PTAN for the provider & have the benefits been reassigned to the group?:
What will you be Billing under
PAYOR MIX (% of patients per payor)
Providers List
PROVIDER NAME
CREDENTIALS
BOARD CERTIFIED: yes or no
SPECIALTY
EMAIL:
CELL PHONE
 
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