Billing Client Discovery Form

Billing Client Discovery Form

Purpose:This form focuses on gathering information on EHR/PM software, fee schedule, clearinghouse, and payer set-up, plus payer portal access, payer enrollments, EDI/ERA/EFT set-up, billing workflow, financial reporting, and go-live readiness.
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 & Implementation Team

3. Addresses, Legal Entities & Identifiers

Physical Address / Service Location

Billing Address

Mailing Address

4. Setup Readiness & Project Timeline

5. Provider Information, Credentialing & Billing Roster

Add one record per provider requiring credentialing, payer enrollment, software setup, or billing setup.

Provider Types / Roles

6. Credentialing, Payer Enrollment & Contracting Needs

Credentialing / Enrollment Scope

Requested Payers / Networks

Commercial Plan Details

Medicaid Details

Medicaid MCO Details

Medicare Advantage Details

Exchange / Marketplace Details

EAP Details

Behavioral Health Carve-Outs

Medicare Details

Workers Compensation Details

7. EHR/PM Software & Clearinghouse Setup

System Setup Tasks Needed

8. EDI, ERA, EFT & Connectivity Enrollment

9. Services Offered, Charge Capture & Coding Setup

10. Future Billing Workflow Design

11. Billing Services Requested

12. Front Desk, Eligibility, Prior Authorization & Patient Billing Setup

13. Reporting, Meetings & Success Metrics

14. Access & Documents Needed

Secure Document Uploads

15. Transition Plan & Go-Live Readiness

16. Risk Flags, Compliance & Additional Notes

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. Documents containing protected health information, personally identifiable information, banking information, or other sensitive data must be uploaded only through the approved secure portal and should not be sent through unsecured email.
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