RMS Prospective Client Information

1
Please take a few moments to complete the following survey regarding the practice /
facility. Your answers to these questions will allow us to identify your needs and enable us to provide an accurate and competitive quotation on professional fees and scheduling for a site visit. If you need more room for some responses, please feel free to attach an additional sheet of paper.
2
Practice Name* This field is required.
3
Practice Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Best Contact Number* This field is required.
Please enter a valid phone number.
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Specialty* This field is required.
7
Number of Billing Providers* This field is required.
8
Year practice was established?* This field is required.
9
How many practice sites are there?* This field is required.
10
How many sites would you like us to visit as part of the consultation?* This field is required.
11
As the result of this consultation, what issues/areas do you want to be demonstrably different? Admin / Physician response (required):* This field is required.
Yes
No
Coding & Billing
Row 0, Column 0
Row 0, Column 1
Accounts Receivables Management (Improve cash receipts)
Row 1, Column 0
Row 1, Column 1
Staff Training
Row 2, Column 0
Row 2, Column 1
Staff Turnover
Row 3, Column 0
Row 3, Column 1
Patient Payment Agreement Maintenance
Row 4, Column 0
Row 4, Column 1
Patient Education (Assist the patient in understanding why balances are owed)
Row 5, Column 0
Row 5, Column 1
Verification of Insurance Processes
Row 6, Column 0
Row 6, Column 1
Financial Records Maintenance ( Scanning of financial information for claims)
Row 7, Column 0
Row 7, Column 1
Coding & Billing
Accounts Receivables Management (Improve cash receipts)
Staff Training
Staff Turnover
Patient Payment Agreement Maintenance
Patient Education (Assist the patient in understanding why balances are owed)
Verification of Insurance Processes
Financial Records Maintenance ( Scanning of financial information for claims)
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
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12
Additional issues / concerns:* This field is required.N/A , If none.
13
Clinical Personnel Roster / NPI* This field is required.
14
Identify the most significant strategic challenges you face.* This field is required.
15
Identify any major changes the practice / facility has undergone in the past two years. (Such as mergers, additional or retiring physicians/partners, addition of a new service line, etc.)* This field is required.
16
What additional changes do you anticipate in the future?* This field is required.
17
Do you use a billing service or in-house billing?* This field is required.
Yes
No
18
Software* This field is required.
19
Are you satisfied with the system?* This field is required.
Yes
No
20
Why?* This field is required.
21
Are you using an Electronic Medical Record?* This field is required.
Yes
No
22
EMR Software:* This field is required.
23
What is the practice / facility average patient volume?* This field is required.
Volume
Weekly
Row 0, Column 0
Monthly
Row 1, Column 0
Weekly
Monthly
Volume
Row 0, Column 0
Volume
Row 1, Column 0
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24
What is practice / facility year-to-date?* This field is required.
$/%
Gross Charges
Row 0, Column 0
Net Collections
Row 1, Column 0
Annual Revenue 1 (one) year prior
Row 2, Column 0
Annual Revenue 2 (two) year prior
Row 3, Column 0
Current Insurance Accounts Receivables
Row 4, Column 0
Current Patient Accounts Receivables
Row 5, Column 0
What % of the AR are over 90 days old?
Row 6, Column 0
Gross Charges
Net Collections
Annual Revenue 1 (one) year prior
Annual Revenue 2 (two) year prior
Current Insurance Accounts Receivables
Current Patient Accounts Receivables
What % of the AR are over 90 days old?
$/%
Row 0, Column 0
$/%
Row 1, Column 0
$/%
Row 2, Column 0
$/%
Row 3, Column 0
$/%
Row 4, Column 0
$/%
Row 5, Column 0
$/%
Row 6, Column 0
1 of 7
25
Are you satisfied with the practice / facility collection ratio?* This field is required.
Yes
No
26
Who are your top 10 carrier?* This field is required.
Should be Empty: