Integrated Tech Solutions
           Questionnaire

 
 
  *Name     
  *Practice Group    
  *Address *Indicates Required Fields
    Suite *City
  *State *Zip
  *Phone   Fax
  *E-mail *Contact
  Number of Claims Per
  Month
  Number of Procedures
  Per Claim
  Average Monthly Billing $
  Average Monthly
  Collection                      $
  Average Days Sales
  Outstanding
 
  Number of Patient
  Statement  per  Month
  Are You a Participating
  Physician with Medicare

Percentage of Billing :
Medicare : %
Medicaid  : %
HMO/PPO: %
Commercial : %
Self-Pay : %
Any Other Comments.
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