New Practice Submission Form

Name Of Person Submitting This Form

Title

Callback Number

Legal Name of Practice

Practice Type

Practice Primary Address

Additional Locations

Main Phone

Fax

Number of Locations

Number of Providers

Current Patient Volume per Month

Pre-Covid-19 Patient Volume per Month?

Expected number of tests per month

Practice Days and Hours

Payer Mix (list by %)

Are any of your payors capitated?

Please list

All Practicing Doctors Name and Specialties

PRIMARY CONTACT (Physician/Owner)

Primary Name

Title

Phone

OFFICE MANAGER CONTACT INFORMATION

Primary Name

Title

Phone

BILLING MANAGER CONTACT INFORMATION:

Primary Name

Title

Phone

DOES PRACTICE USE 3rd PARTY BILLING?

Yes No

If yes, name.

Pulse4Pulse Service: Will PRACTICE USE P4P BILLING or SELF-BILL?

Additional Notes

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