Reimbursement Analysis Survey

Thank you for taking the first important step in your journey to Financial Ease!

Please complete all fields and answer the following questions; your report
will be delivered as soon as you finish.

*Clinic Name
*Address 1
Address 2
*City
*State
*Zip Code
*Phone
Fax Number

*Doctor’s First Name
*Doctor’s Last Name
*Email Address
Cell Phone

Do you ever charge your Medicare patients cash for active care or medically necessary adjustments and not bill Medicare?

Yes
No
I don't know

Do you get ABN forms signed every visit?

Yes
No