Thank you for considering CMBS for your revenue management services. Please complete the worksheet below to help us better understand your practice and billing needs. The information you provide will allow us to assess how our billing services can best support your goals and streamline your revenue cycle.

Please enable JavaScript in your browser to complete this form.

Practice/Physician Information

Specialty *

Number of providers (including PA and NP) *

Number of locations (include Hospitals) *

Does the provider code their own work? *--- Select Choice ---YesNoUnsure

Name of EMR *

Can their EMR provide demographics and patient reports electronically through an interface? *--- Select Choice ---YesNoUnsure

County and state of Location(s) *

Are there any current concerns regarding billing *--- Select Choice ---YesNoUnsure

Do they currently bill in-house or outsource *--- Select Choice ---YesNoUnsure

Special request(s) or needs unique to the practice *

12 (including Special

12 Month Average

Daily Procedures/Visits *

Monthly Billed Charges *

Monthly Adjustments *

Monthly Refunds *

CurrentTotal A/R *

0-30 *

31-60 *

61-90 *

91-120 *

Over 120 *

Gross Collection % (Gross Pmt/Gross Chg) *

Net Collection % (Net Pmt/Net Chg) *

Current Metrics

Days in A/R *

60 Day Resolution of Claims *

Charge Entry Variance *

% of Claims over 120 days *

Credit Balances (as a % of revenue) *

Submit