Care Cloud – Practice Information

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PRACTICE INFORMATION

Practice Name:*

Tax ID#:*

Check Practice Type:

Solo

Group

Number of physicians (If Group):

Practice/Group NPI:*

PHYSICAL ADDRESS OF THE PRACTICE

Street Address:*

City:*

State*

Zip Code*

Office Tel:*

Office Fax:

BILLING ADDRESS OF THE PRACTICE (IF DIFFERENT FROM PHYSICAL ADDRESS)

Street Address:

City:

State

Zip Code:

OTHER LOCATIONS OF THE PRACTICE (IF ANY)

Location

Street Address:	City	State	Zip Code	Office Tel:	Office Fax:	Actions

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OFFICE CONTACT INFORMATION

Contact person:

Contact person’s email address:

Contact person’s Tel:*

Contact person’s Fax:

IT Contact person:

Availability:

Contact #

FINANCIAL CONTACT INFORMATION

Financial contact person:

Financial contact person’s email address:

Contact person’s Tel:

Contact person’s Fax:

PROVIDER INFORMATION

CONTACT INFORMATION PER PROVIDER ((ADD ADDITIONAL SHEETS IF MORE THAN ONE PROVIDER))

First Name*

Last Name*

Credentials:

Specialty:

Soc. Sec#:

DOB:

DD slash MM slash YYYY

Provider NPI:*

Office Tel:

Office Fax:

Emergency Contact:

Private Line:

Cell Phone:

Home Tel:

Home Fax:

Provider’s email address:

ATTACH CLEAR COPIES OF THE FOLLOWING DOCUMENTS & INSURANCE EOBs

DEA#:

DEA EXPIRY DATE:

MM slash DD slash YYYY

LICENSE#:

CLIA#:

CLIA EXPIRY DATE:

MM slash DD slash YYYY

Attachments

Drop files here or

Max. file size: 2 MB.

Provider

MI	Credentials:	Specialty:	Soc. Sec#:	DOB:	Provider NPI:	Actions

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HOSPITAL/ NURSING HOME AFFILIATIONS

Hospital

Name	Address	Phone Number	NPI	Actions

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INSURANCE PROVIDER’S NUMBERS

Please List Down the Major Insurance(s) You Are Enrolled or Do Billing with:

Group/Provider Name

List

INSURANCE NAME

PROVIDER ID #

GROUP #

PAR

NON-PAR

CONFIRMED (FOR CareCloud USE ONLY)

OFFICE EMPLOYEES

List

NAME

RESPONSIBILITIES

DAILY WORK HOURS

FEE SCHEDULE & PATIENT STATEMENT

Fee Schedule:

Client Response

Additional Information

Would you like to use our enhanced fee schedule?

Yes

If No, please provide your own fee schedule.

File

Max. file size: 2 MB.

Would you like to charge for No Shows?

Yes

If Yes, please mention the amount?

Would you like to charge a fee for bounced checks?

Yes

If Yes, please mention the amount?

Should we use any other number for patients to callback and Days and Time to call or should we use CareCloud's number on the statement?

Would you like us to bill the patients directly or would you like to have an option on the website so you can choose to bill the patient or write-off a balance?

What Pay to address should we mention on statements sent out to patients for them to make payments?

What payment method do you use in order to take payments from patients like credit card or only accept check?

If you accept credit cards, which cards do your office accept? (Visa, MC, Amex, Discover)

Can we send e-statements? If patient has email address.

What will be the minimum amount on which a balance reminder call be generated?

(Equals or above than $1.00)

What will be the minimum amount on which a Paper statement should be generated?

(Equals or above than $1.00)

Number of patient statements be sent for any claim. One, two or three until it’s paid.

Can we move patient balance in different DOS if patient overpaid in one claim and amount is due on the other from patient?

Yes

Should we contact your office for COB (Coordination of Benefits) information before sending patient statements?

Yes

Should we call patients for expired insurances and get the updated insurances information from them directly?

Yes