Provider Intake Questionnaire Provider's Name *Practice Name *Other Dr. NamesPhysical Address *Phone Number *Email Address *Out of Network *YesNoIn Network *YesNoWhat insurance do you currently accept? *What is your average monthly insurance reimbursement? *What is your average monthly patient intake? *What are your most common used procedure codes? *What area does your practice need improvements? *What are 3 goals your practice would like to accomplish in the following 6 months? * Submit
