Provider Intake Form

Please take a moment to complete this brief questionnaire to better assist us in providing you the best possible guidance and service.  Thank you for your interest in Advanced Practice Claims.

Provider Intake

* indicates required field

Name:*

 

Email:*

 

Practice Name:*

 

Phone:*

 

Practice Address:*

 

What is your specialty?:*

 

Number of Practice Providers:*

 

Select the services in which you are interested:*

Billing (full service)
Billing (claims only)
Billing (patient only)
Billing (Audit and Cleanup)
EHR (full setup and implementation)
EHR (consultation only)
Credentialing (full service)
Credentialing (CAQH only)
Practice Management (complete)

 

Is your practice in network with any insurance carriers?*

 

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