Client Intake Screening

Thank you for choosing Alpha Billing Solutions. Prior to our 30 minute initial consultation, please fill out this form in order for us to get to know you and your business!

Client Intake Screening

Practice Name *

Name of person completing the form *

Phone *

Email *

Street Address *

City *

Zip *

Medical Office Type *

How many therapists do you have in your practice? *

Who currently does your billing? *

Who currently does your client intakes? *

What EHR do you use? *

What insurances are you currently in network with? *

Check yes or no to the following.

Do you bill secondary? *

Yes

No

Do you bill medical assistance and/or medicare? *

Yes

No

Do you bill pre-licensure? *

Yes

No

Do you bill interns? *

Yes

No

Does your office need credentialing? *

Yes

No

If you are human, leave this field blank.

Submit