Client Intake Form

This Client Intake Form consists of 8 sections. Submission will only be accepted once all required fields have been filled out.

TriumpHealth Intake Form

SECTION 1: GENERAL INFORMATION

Organization/Group Name *

Full Legal Name (including DBA) *

Tax Designation *

Practice Type *

Specialty/Subspecialty *

If “Other”, fill the next field.

State(s) of Operation *

Hold Ctrl/Cmd to select multiple states.

Number of Locations *

Opening Date *

Website URL (if applicable)

Primary EHR System Used *

SECTION 2: CONTACT INFORMATION

Primary Contact – Name *

Primary Contact Title *

Primary Contact Phone *

Primary Contact Email *

Secondary Contact – Name *

Secondary Contact Title *

Secondary Contact Phone *

Secondary Contact Email *

Business Phone *

Business Fax (Required for CMS)

Business Physical Address *

Business Billing Address *

Business Mailing Address *

Preferred Contact Method *

Best Time to Contact *

SECTION 8: AUTHORIZATION & ACKNOWLEDGEMENT

Attachments (if applicable)

Upload documents here (we will send them to ShareFile). You can select multiple files.

Additional Comments / Notes

I acknowledge and agree to the terms. *

Date Signed *

Typed Signature (Full Name) *

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Healthcare Organizations

Medical Specialties

Client Intake Form

SECTION 1: GENERAL INFORMATION

SECTION 2: CONTACT INFORMATION

SECTION 8: AUTHORIZATION & ACKNOWLEDGEMENT

Maximize Your Revenue. With Expert RCM Services

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