Billing Client Intake Form | TriumpHealth

Billing Client Intake Form

Purpose:

This form focuses on gathering information on the wound care providers, practice, services offered, location, documentation, and payer details needed to assess Medicare/Medicaid, Medicare Advantage, Medicaid MCO and commercial payers credentialing and enrollment requirements.

Instructions:

• Complete every applicable field. Select only services currently provided or planned.

• Upload supporting documents through the secure upload fields. Do not email protected or sensitive documents.

• Items marked “if applicable” may not apply to every provider or practice. Upload documentation through the secure portal only.

• Submission does not guarantee payer approval, network participation, or reimbursement.

Form completion0%

Section 1 - Client & Contact Information

Client Type
Main POC Title / Role
Preferred Contact Method

Best Time to Contact

Select the preferred contact time for each applicable weekday.

Monday
Tuesday
Wednesday
Thursday
Friday

Section 2 - Organization & Practice Information

Include DBA, if applicable.
Tax Designation
Multiple TINs Used?
Ownership Information

Add each owner separately so the ownership details are clear and ready for AWS processing.

Select the date using the calendar icon.
For telehealth-only practices, enter 0.

Primary Physical / Service Location

Billing / Mailing Address

Fax may be needed for payer, CMS, and billing communications.

Section 3 - Practice Type, Specialty & Billing Identifiers

Practice Type
EHR / Practice Management System
Clearinghouse

Section 4 - Services Offered & Billing Readiness

Be specific, as this impacts code setup, payer rules, authorization needs, and billing workflow.
Optional at intake; may be collected during onboarding if not available.
Place of Service UsedSelect every POS code that may be used for billing.
No matching POS code was found.
Estimated visits / claims per month.
Current Billing Status

Section 5 - Providers to be Included

Complete one entry per provider. Attach a roster if more space is needed.

The selected file can later be sent to S3 through a secure pre-signed upload URL before final submission.

Section 6 - Billing Scope of Work

Billing Services Requested
Claim Types
Payer Categories
EDI / EFT / ERA Needed?
Transition Needs

Section 7 - Current Issues / Risk Flags

Known Billing Issues

Section 8 - Client Acknowledgment

Use a mouse, touchpad, or touchscreen to sign.
Draft saved locally.

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