Coding and Documentation Request for Proposal

Coding and Documentation Request for Proposal 

Practice Name:
Physician Name(s):   
Contact Name:
Address:
City:
State:
Zip:     
Phone Number (please include dashes):
Fax Number:
Other Number:
E-Mail Address:
Specialty:  

Number of Total Providers:       MDs
  DOs
  PAs
  NPs

How Did You Hear About Our Services?
(If you heard about us from another physician,
please let us know their name)

How do PAs or NPs Bill?
         
Are You a TMA Member?
         
Service Requested:
 
If you are requesting the comprehensive audit,
are you interested in acquiring CME hours for an 
additional fee?
         
Medical Records:
         
Practice Management Software:
EHR Software:  

Which documentation guidelines are
currently used?
 
         
Main concern of practice?  
Comments:  

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