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Request for Quotation

Thank you for considering DNR Medical Management. In order that we may accurately and fairly prepare an estimate for you, please fill out the information below. We base our quotation and any future contractual agreement on the information contained herein, so accuracy and full disclosure is very important. We believe it to be of utmost importance in a long-term business relationship for us to fairly estimate your costs for you.

Practice Name(s), Specialty, # of Providers and year of formation How is your billing currently being done (manually, computer, billing service, other)? Why are you contacting us to inquire about our billing services? What problems are you experiencing, if any?

What is your billing setup?

In-House Outsourced New Practice

What is your practice make-up? (List how many)

MD/DO PA NP DC LMT PT

What is your practice's insurance makeup, based on dollars billed?

Medicare %
Medicaid %
Blue Cross %
Commercial %
Worker's Comp %
No Insurance/Cash %
HMO Contracts %
PI/Med Pay/Liability %

Are you a participating provider with Medicare, Medicaid, and BCBS? Worker's Comp? Which HMO's/PPO's? How many patients per day (average) are seen at your office? What is the average patient re-imbursement per visit? Please estimate the number of claims you submit to insurance companies each month. About how many bills (statements) are sent to patients each month? What are your average billings(charges) per month? % of rejected claims? Types of rejections? What are your average collections (payments) per month? How much money is currently outstanding (receivables)? Do you want us to recover your aging accounts receivable? How would you like us to contact you? Please provide phone address or email address if applicable.

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