First priority provider collection form

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Provider Information Collection Form for FP

Name

First Last

Specialty

Website

How many locations does this provider have where we will send cases?

Address - Location #1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Does this address have free of paid parking? If paid do they validate?

Address - Location #2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Does this address have free of paid parking? If paid do they validate?

Main Point of Contact for Scheduling

Main Point of Contact for Reports

Front Desk Receptionist

Biller Information:

Does this provider offer Telemedicine appointments?

Does this provider have a specific process for Telemedicine patients? Please list your requirements:

Does your practice send out automated appointment reminders?

Yes

Spanish Speaking Patients: Does this provider have someone who speaks Spanish who is able to translate?

What is the approximate turnaround on reports and bills?

What Surgical Facility/Facilities does this operate out of with address? Only list facilities where First Priority has a contract

Please list the point of Contact for the Surgical Facility: Administrator & Billing Department with emails and phone number.

Who do we contact for Anesthesia reports and bills?

Notes:

Please list any information we should know about working with this provider.