Billing-Only Client Discovery Form

Credentialing Client Discovery Form

(Billing-Only)

Purpose:

This form focuses on gathering information on existing billing operations, transition readiness, A/R, denials, reporting, and ongoing revenue-cycle support.

EHR/PM software, clearinghouse, payer portal access, and active payer enrollments are expected to be already established.

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.

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1. Client & Practice Information

2. Contacts & Communication

3. Addresses & Organization Identifiers

Primary Physical / Service Location *

Billing Address

Mailing Address

Organization Billing Identifiers

Enter exactly 9 digits.
Enter exactly 10 digits.

4. Locations & Hours of Operation

Add each billing/service location and enter its hours of operation.

5. Baseline Billing Volume & Current Status

6. Provider Information & Billing Roster

Add one record per billing or rendering provider.

Billing Type Options

7. Services Offered & Charge Capture

8. Existing Systems, Access & Connectivity

9. Payers, Credentialing & Enrollment Status

Payers / Insurance Plans to Bill *

10. Current Billing Workflow & Transition

Secure Access & Document Uploads

Privacy, Security & Technology Requirements

Please review the following requirements carefully before submitting this Billing-Only discovery form.

Privacy, Confidentiality, and Security of Credentialing and Billing Documents

To maintain compliance with HIPAA and to safeguard Client privacy, confidentiality, and data security, TriumpHealth strictly prohibits the transmission of credentialing, billing, payer, patient, financial, or other sensitive documents through unsecured email, postal mail, or fax.

Technology Platform Usage Requirements

All documents required for onboarding, billing transition, payer setup, A/R review, reporting, and related revenue-cycle services must be uploaded directly by the Client through TriumpHealth’s approved secure technology workflow. Failure to use the approved secure process may result in delays or inability to proceed.

If the Client is unable to navigate the required technology after initial onboarding and workflow training, TriumpHealth will provide one additional training session at no additional cost.

If the Client does not effectively use the approved secure platform and fails or refuses to provide the required documentation within three (3) months of onboarding, TriumpHealth shall have no obligation to continue processing the applicable services, and the Client shall not be entitled to any refund or credit of amounts paid under the Agreement.

Payer / Portal / System Access

Where payer portals, clearinghouse access, EHR/PM access, payment-system access, or other third-party system access is required to perform the agreed services, the Client is responsible for providing timely, accurate, authorized access. TriumpHealth is not responsible for delays, denials, rejections, or incomplete work caused by unavailable or inaccurate access credentials or permissions.

Primary Location Address

I verify that the primary service location information provided above is accurate and is not a virtual office, mail drop, P.O. Box, mailbox service, or other address that would fail payer or billing requirements where a compliant physical service location is required.

Pricing Terms

The pricing set forth in the executed Agreement is contingent upon the Client’s adherence to TriumpHealth’s recommended technology platforms, workflows, documentation requirements, and timely cooperation.

Scope of Work Precedence

In the event of any conflict, inconsistency, or discrepancy between the Scope of Work set forth in the executed Service Agreement and information provided in this Billing-Only Client Discovery Form, the terms of the executed Service Agreement shall control and be deemed final and binding.

Please fill and sign below to confirm that all information completed above is true and correct and that you have reviewed and agree with the requirements above.

Client Authorization & Acknowledgment

Signature

✍ Draw Signature
⬆ Upload Signature

Use a mouse, touch screen, or stylus.

Disclaimer: Completion of this form does not guarantee payer approval, claim payment, reimbursement amount, collection outcome, or payer processing time. Sensitive documents must be uploaded only through the approved secure portal and should not be sent through unsecured email.

Thank You!

Your Billing-Only Credentialing Client Discovery Form has been submitted successfully.

Your form is currently in review.

Our Billing team will review your information and supporting documentation and contact you if additional information is required.

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