Provider Information Collection Form

Provider Information

Name

First Last

Specialty

Billing Address for Contract

Street Address City State ZIP Code

Website

End Provider Information

Practice Information

How many locations do you have?

We can service up to two locations

You can add the office information for those locations below.

Hidden

What two locations would you like to see patients at

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 you 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 you validate?

Your Team

Main Point of Contact for Scheduling

Main Point of Contact for Reports

Front Desk Receptionist

Medical Assistant

Biller Information:

Main point of contact for Invoices

Practice Information

Treatment

What is your clinic Schedule?

Can you offer appointment block time to Elite Medical Care?

Do you offer Telemedicine appointments?

What is your process for Telemedicine patients? Please list your requirements:

Does your practice send out automated appointment reminders?

Yes

Do you have a preferred MRI facility ?

For MRI Review: Do you consent to obtain access to online MRI portals if a patient forgets their MRI CD?

Spanish Speaking Patients: Do you have someone who speaks Spanish who is able to translate?

What is your turnaround on reports and bills?

Treatment

Surgery

What is your surgical schedule?

What Surgical Facility/Facilities do you operate out of?

Please list the point of Contact for the Surgical Facility: Administrator & Billing Department

Do these facilities work with Funding Companies?

Surgery

Fee Schedule

Do you hold your professional lien?

What is your fee schedule?

Here you can list for fees for Initial Consults and Follow Ups etc

Would you like Elite Medical Care to assist in Settlements?

Yes

Open to discussion

Fee Schedule

Med Legal

Are you open to working up cases?

Are you open to taking cases going to Trial?

Med Legal

Items to Upload

Max. file size: 5 GB.

Headshot

Max. file size: 5 GB.

Bio

Max. file size: 5 GB.

Bio