Suitemed IMS Client Questionnaire

Please complete the following questions to in order to help start the implementation process.

* Required

Business Name * Enter your business name as associated with your Tax ID

Business Address * Enter in your Physicial address for the practice

Business City * Enter in your City for the practice

Business State * Enter in your State for the practice

Business Zip Code * Enter in your Zip Code for the practice

Published Telephone Number * Enter in your Published Telephone Number for the practice

Backline (If any) * Enter in your Backline Number for the practice

Published Fax Number * Enter in your Fax Number for the practice

Business Email * Enter in your Business Email for the practice

Business Website (If Any) * Enter in your Business Website for the practice

Business Tax ID * Enter in your Business Tax ID for the practice

Business NPI * Enter in your practice NPI number for the practice

Billing Address If Different From Business Address * Enter in your Billing Address for the practice

If your providers are rendering services at more than 1 location please enter them below Please enter in the complete information for the additional offices below.

Provider Full Name * Please enter the Providers Full Name

Provider Speciality * Please Enter in the provider's speciality, if provider is listed with multiple specialities please specify all of them below. (Please include Taxonomy Codes if available)

Provider Date of Birth * Please enter the Providers Date of Birth

Provider Individual NPI * Please enter the Providers Individual NPI

Provider Individual Tax ID * Please enter the Providers Individual Tax ID if the provider Bills under his individual Tax ID

Provider State License # * Please enter the Provider State License #

Provider DEA Number * Please enter the Provider DEA Number #

For multiple providers, please use the text box below to include additional providers information Please enter all additional providers information below

Does the provider bill under Tax ID or Social Security? * Please select how the provider is currently being billed under

Individual Tax ID
Group Tax ID
Social Security

Does the provider bill under Individual Tax ID or Group Tax ID? * Please select how the provider is currently being billed under

Individual Tax ID
Group Tax ID

Is the Provider part of a Provider group? If the provider is part of a provider group, please list the name, address, and NPI of which you see in box CMS 33. Please provide the provider group NPI found in CMS 1500 Box 33A

Please provide the providers 6 digit group PTAN number for Railroad Medicare Please be sure to provide the Providers PTAN number and Group NPI for Railroad Medicare for Clearinghouse Enrollment.

Please provider the providers 6 digit group PTAN number for Medicare Please be sure to provide the Providers PTAN number and Group NPI for Medicare. If the provider bills under individual, please provide Individual NPI.

Please provider the providers 10 digit PTAN number Please be sure to provide the Providers 10 digit PTAN Provider number and group NPI". If the providers bills under individual, please provide individual NPI.

Please list all employees in the practice that will be using Suitemed IMS * Please list the employees full name, email, extension, department they belong to, job responsibilities.

Do you intend to bill in-house or use an outside billing compan? If you are currently using an outside billing ocmpany please include the contact information below (Company name, contact name, email, phone)

Are you currently using a clearinghouse? If you are currently using a clearinghouse, please provide the clearinghouse name, phone number, contact person, and website.

If you you are planning on interfacing Suitemed IMS with your labs please include the contact information for EACH Lab below. Please provider the Lab name, Lab Rep, Phone number, Email, Website, Other Details

Please provide the provider schedule detail below * Please provide the Providers name, Day, Time, lunch/breaks/blocked times. For Example: Provider name: Dr. smith, Day: Monday-Friday,Time: 8:00-5:00, Lunch: 12:00-1:00, Surgeries: Fridays 2:00-5:00

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