Detailed Office Assessment

This is a continuation of the Application process.

This information will be appended to the information provided on the initial application form.

NOTE: Please be sure to use the Doctor’s primary email, as it was entered on the initial application,
even if you are filling this out on his/her behalf.

Office Assessment

"*" indicates required fields

Step 1 of 3

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Provider Email*

Enter Email Confirm Email

Provider Name*

First Last

Practice Name*

Preferred Contact Method*

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Provider Role

Office Phone Number*

Mobile Phone Number

Office Fax Number*

NPI*

Do you have an Emergency Phone Number?

Yes

What is the Emergency Phone Number?*

Street*

City*

State*

Zip Code*

Provider Practice Structure*

Provider Medical License Type*

Medical Specialty Practiced*

Medical Sub-Specialty (Free-Form)

Other Medical Specialty Practiced (Free-Form)

Please List Board Certifications*

Please Select any Fellowships

Number of Years in Practice*

Please enter a number from 1 to 50.

Number of Years at Current Location*

Please enter a number from 1 to 50.

Hours of Operation*

If Other Fellowships, Please Specify

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On-Site Diagnostics Done

Are On-Site Diagnostics Done?*

Yes

Please list the type of Diagnostics Done On-Site*

Are You HIPAA Compliant*

Yes

Do you offer Translation Services?*

Yes

If Yes, what languages?*

Who is Your Trust Certified Liaison*

Trust Certified Liaison Phone Number*

Trust Certified Liaison Email*

Enter Email Confirm Email

Do You Have a Surgical Coordinator?*

Yes

Name of Surgical Coordinator*

Surgical Coordinator Email*

Enter Email Confirm Email

Do You Have a Billing Manager?*

Yes

Name of Billing Manager*

Billing Manager Email*

Enter Email Confirm Email

Do You Have a Dedicated Scheduling Person?*

Yes

Scheduling Person's Name*

Scheduling Person’s Email*

Enter Email Confirm Email

Please Describe Your Scheduling Process*

Please specify the Number of Support Staff

Number of Clerical Staff*

Please enter a number from 0 to 50.

PA/NP/Medical Assistants*

Please enter a number from 0 to 50.

Other Support Staff*

Please enter a number from 0 to 50.

Is Your Staff Cross-Trained?*

Yes

What is Your Internal Process for New Patients?*

Do you Confirm Appointments Prior?*

Yes

Do You Collect Demographics?*

Yes

Do You Collect Picture ID?*

Yes

How do you Confirm Appointments Prior?*

What Forms Do You Use with Patients?*

Please list all forms used and upload them.

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Please Upload All Patient Forms/Materials Used

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, Max. file size: 128 MB.

Are Quick Notes Completed Within 24 Hours?*

Yes

Who Completes Quick Notes?*

What is your Billing Frequency?*

Explain Billing Process*

What is your Report Frequency?*

Explain Report Process*

Are Intake Forms Reviewed for Completeness?*

Yes

Who Reviews Intake Forms?*

Are Prescriptions Auto-Faxed?*

Yes

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Who sets up Auto Faxing?

Is There a Prescription Monitoring System in Place?*

Yes

Who Completes this Process?*

Do you have a Controlled Substance Management Process?*

Yes

Do you have Onsite Controlled Substance Testing?*

Yes

Who performs the Testing?*

What is the Testing Process?*

What is your Ratio of Patients to Procedures?*

Do you keep Clinical Outcomes?*

Yes

Do you Practice Anywhere in Addition to your Private Practice?*

Yes

How many locations do you practice at?*

Location 1 Address

Street*

City*

State*

Zip Code*

Phone Number*

Practice type*

Private Practice

Surgical Center

Hospital

Clinic

Schedule*

Location 2 Address

Street*

City*

State*

Zip Code*

Phone Number*

Practice type*

Private Practice

Surgical Center

Hospital

Clinic

Schedule*

Location 3 Address

Street*

City*

State*

Zip Code*

Phone Number*

Practice type*

Private Practice

Surgical Center

Hospital

Clinic

Schedule*

Location 4 Address

Street*

City*

State*

Zip Code*

Phone Number*

Practice type*

Private Practice

Surgical Center

Hospital

Clinic

Schedule*

Location 5 Address

Street*

City*

State*

Zip Code*

Phone Number*

Practice type*

Private Practice

Surgical Center

Hospital

Clinic

Schedule*