Prospective Client Form

Agency Name *:

Agency Location *:

Main Contact Name *:

Main Contact Phone # *:

Main Contact Email *:

How did you hear about us? (select all that apply)
WebsiteInternet SearchFacebookReferralOther
 

Choose from the services we provide: (select all that apply)
Revenue Cycle Management (Billing/Collections)Authorization and Eligibility ChecksCredentialingConsultation
 

Notes: Tell us about your agency:

Number of Clients:

Number of Admin Staff/Other:

Number of BCBA's:

Number of RBT's:

Software Used (or plan to use): (select all that apply)
Central ReachRethinkKareoAccupointWebABANPA WorksOther
 

Funding Sources: (select all that apply)
UnitedBCBSAetnaCignaMedicaidSchool District(s)Other