First Name
Last Name
Clinic Name
Email
Please tell us the main reason you enrolled with ChiroHealthUSA and want to offer it to your patients?
When was the last time that your actual fees were updated? Within the last 6 months6-12 months agoLonger than 1 year ago
Have you recently calculated your cost per patient visit? YES NO
If YES, what is your cost per patient visit?
Does your office ever give away free services? YES NO
% of your Patients that are Cash Patients
% of your Patients that are Insured
% of your Patients that are Medicare Patients
% of your Patients that are Personal Injury Patients
% of your Patients that are Workers Comp Patients
Average # of New Patients per Month
How many insurance carriers is the practice in-network (contracted) with?
How many insurance carriers is the practice contracted with Out of network?
Please list the TYPICAL SERVICES that you provide a New Patient COVERED BY INSURANCE (never been to your office or not been there in 3 years) and your ACTUAL FEE (highest fee for that service in your office). (Example: 99203: $150; 72040: $75; 98941: $50)
If a NEW MEDICARE or NEW CASH patient came into your office and received the same services, noted above, would the codes and fees be the same? YES NO
If Not, explain:
Do you perform x-rays in your office? YES NO
If yes, do you typically perform x-rays on your patients’ first visit? YES NO
Of course, every patient visit is unique. Please list the most TYPICAL SERVICES that you provide on ROUTINE patient visits, COVERED BY INSURANCE. (Example: 98941: $50; 97014: $30; 97110: $50)
If an ESTABLISHED CASH PATIENT received the SAME SERVICES noted above, would the codes and fees be the same? YES NO
If not, please list the usual codes and fees charged.
Does your office have a charge for CASH patients who receive only an adjustment? YES NO
If so, what is it?
Does your office routinely perform “Maintenance” or “Wellness” visits? YES NO
If yes, is the charge for this type of visit the same as it is for a routine visit? YES NO
We’d like to explore how your office handles daily services excluded from Medicare coverage. Please list the services that you typically provide on a routine visit for your Medicare patients, include code and actual fee. (Example: G0283: $30; 97012: $30)
Does your office currently offer any type of Family Discount Plan? YES NO
If yes, please describe:
Does your office belong to any other Discount Medical Plan Organizations (besides ChiroHealthUSA)? YES NO
If yes, please list:
Does your office offer any discounts other than the ones that have been indicated in this questionnaire? YES NO
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