Provider_PT/Chiro Collection Form

Name

First Last

Specialty

Billing Address for Contract

Street Address City State ZIP Code

Website

How many locations do you have?

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?

Address - Location #3

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?

Main Point of Contact for Scheduling

Main Point of Contact for Reports

Front Desk Receptionist

Biller Information:

Main point of contact for Invoices

What is your clinic Schedule?

Does your practice send out automated appointment reminders?

Yes

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

What is your turnaround on reports and bills?

Max. file size: 5 GB.

Headshot

Max. file size: 5 GB.

Bio

Max. file size: 5 GB.

Bio