Shoreline Medical Billing
Phone: 888.485.8883
Fax: 888.485.8883
info@shorelinemb.com
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Client Data
Your name:
Practice name:
Type of practice:
Specialty:
Contact person:
Phone number:
E-mail:
Mailing address:
Practice Data
Number of providers in practice:
providers
Top 3 insurance carriers:
Are claims processed electronically?:
Yes
No
Claims processing:
Name of billing software:
Monthly in-house billing cost:
Monthly billing company cost:
Insurance Data
# of claims per month:
Paper
Electronic
Average value per claim:
$
% of unpaid claims due to billing errors:
5%
10%
15%
20%+
Approximate amount of A/R:
$
Current aging A/R in days:
15-30
31-60
61-90
91+
Reimbursement turnaround time in days:
15-30
31-60
61-90
91+
What % of claims are uncollectable?:
5%
10%
15%
20%+
Advantages of your current billing process:
Disadvantages of your current billing process:
© 2009 Shoreline Medical Billing, LLC • Serving Southern California • Based in Ladera Ranch, CA •
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