Billing Services Questionnaire

Thank you for your interest in GroupOne’s Billing and Reimbursement Management services.  The information requested below will help us prepare a service quote for your practice.  Please return the requested information below at your earliest convenience and a proposal will be returned for your review and consideration.  Please do not hesitate to contact us at 954 779 6118 if you have any questions or if we can assist you in any manner.

1. Last 6 months charges:


2. Last 6 months collections:


3. Last 6 months adjustments:


4. Payor Mix (percentage estimates):


5. Average # of patients seen in clinic per day per provider:


6. Average # of procedures/surgeries/visits in hospital per day per provider:


7. Any anticipated changes in provider staff over the next year, if applicable:


8. Current practice management system:


Practice Name:
Client Contact Name:
Client Contact Telephone #:
Client Contact email address:
Number of Providers:
Specialty: