Company Name
*
Contact Name
*
Street Address
*
City
*
State
*
Zip
*
Phone Number
*
Fax Number
E-Mail Address
*
How do you currently check on your patients eligibility status?
Please Select
Don't Check Status
Phone Call to Payer
FISS
Use 3rd Party
Other
What Types of administrative transactions would you like to process through ReChek? Check All that apply. Medicare Coverage (Claims Claims Status, Eligibility)
Home Health & Hospice (Real Time)
Home Health & Hospice (Batch)
BC/BS Eligibility (Real Time)
BC/BS Eligibility (Batch)
Commercial Eligibility (Real Time)
Commercial Eligibility (Batch)
Medicaid Eligibility (Real Time)
Medicaid Eligibility (Batch)
What is the approximate number of Medicare Claims that your organization processes each month?
1 to 100
101 to 600
601 to 1500
1501 to 5000
5000 or more
What is your monthly Medicare census?
25 or less
26 to 60
61 to 100
101 to 200
Over 200
How many NPIs do you bill under?
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