AccuStat Medical Billing, LLC

Application

 

Instructions: Please print out this application. Complete one for each provider/location in your organization. Fax the completed application(s) to 210-579-6582.

 

 

Date: _______________________________________________

 

Name of Provider: ____________________________________

 

Degree: ____________________________________

 

Name of Practice (if different from Applicant):_________________________________________

 

Address of Practice:     ______________________________________________

 

                                    ______________________________________________

 

                                    ______________________________________________

 

Phone:              ___________________________________

 

Fax:                  ___________________________________

 

Tax ID#: _______________________________________

Type of Tax ID#:    □ EIN       □ SSN

 

Name of point-of-contact in your organization with whom AccuStat will

coordinate billing operations: _____________________________________

 

Phone number of point of contact: _________________________________

 

E-Mail Address of point of contact: ______________________________________

 

Type of business or practice: ___________________________________________

 

Medicare Provider numbers: Individual: ____________  Group: ________________

 

Blue Cross Provider numbers: Individual: ____________  Group: _______________

 

Date you wish AccuStat to begin billing operations: __________________________

 

Approximate Monthly Payment Volume: $____________________

 

Is your business a start-up or existing practice: □ Start-up     □ Existing

 

If your practice is existing, why are you changing your billing operations? __________

 

 

 

Are you interested in AccuStat conducting your credentialing process? □ yes    □ no

 

Are you interested in having on-line access to view your billing operations or would you prefer end-of-the-month paper reports?

□ Online Access ($75 fee per month)                        □ Paper Reports (no extra charge)

 

How did you hear about AccuStat Medical Billing LLC: _________________________________________________

 

 

Thank you for completing this application. Please fax this to AccuStat at 210-579-6582. An operations manager will call you with a quote. After this, a contract will be forwarded to you for signature. The application process takes about 2 days. If you have any questions, please call us at 877-870-2678. Thank you.