General Practice Information & Insurance Balances

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* 1. What is the name of your practice?

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* 2. Please enter your name and your role in the practice.

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* 3. Do you work with an IT company or have an IT resource that manages your network and computer hardware? If you are a Dolphin user, please indicate if you are partnering with MME Consulting and your contact at MME. 
We will not reach out until we've discussed with you first.

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* 4. Please provide the contact information for your IT company: (name, email, and phone number). Who is best point of contact there?

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* 5. Which practice management software are you currently using and what version number? If Dolphin, please indicate whether your server is on site or if you are a Cloud user.

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* 6. What is your standard process for insurance underpays?
At what point (under what $ threshold) would you write off a balance?

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* 7. What is your standard process for insurance overpays?
How long do you wait before crediting back to the patient or adjusting a patient responsibility?

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* 8. Do you submit electronic claims for all carriers? If no, please let us know which carriers are exceptions. Please also provide the clearinghouse website/login that you use if claims are NOT submitted electronically via practice management software.

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* 9. Please list the top insurance carriers that your patient base is enrolled in and that you see at your practice. 

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* 10. Please upload a PDF copy of your Accounts Receivable Aging report (or similar) that breaks down outstanding patient and insurance balances along with amounts and number of days past due.

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