Client Assessment Form
Client Assessment Form
Practice / Clinic Name:
Primary Specialty:
Number of Providers:
Location (City/State):
Contact Person & Designation/Role:
Email
Phone Number:
Average Monthly Chart Volume
Peak Season Volume (If Applicable):
Payer Mix
- Select -
Medicare
Medicaid
Commercial
Type of Visits (OP/IP/Telehealth/Procedures/ED):
Additional Notes : (If any)
Who currently performs coding? (Name):
- Select -
In-House
Outsourced
Provider
Hybrid
Current Turnaround Time (TAT):
EMR/EHR or Tools Used:
High Denial / Rejection Rate:
Coding Accuracy Issues:
Documentation Deficiency:
Provider Training Needed:
Backlogs or Workflow Delays:
Specialty-Specific Challenges:
Required Services
Coding
QA
Denial Mgmt
Other
If Other (Required Services)
Reporting Requirements
- Select -
Weekly
Monthly
Custom
If Custom (Reporting Requirements)
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