COVER-PRO
SM
APPLICATION
MEDICAL BILLING SERVICE SUPPLEMENT
1. Full name of the Applicant Firm:
2. Does the Applicant have any national
certifications?
Yes No Please provide a list all certifications.
3. How many continuing education credits did the Appl
icant complete in the past twelve month
s?
4. Is the Applicant a member of any national billing / coding associations? Yes No Please prov
ide a list
of all memberships.
5. Please indicate the percentage of the
Applicant’s gr
oss annual revenue from the last fiscal period involving:
Billing / Audit: %
Transcription: %
Coding: %
Collections: %
Other:(specify) %
TOTAL M
UST EQUAL 100 %
6. Doe
s the Applicant provide record storage for a third party?
Yes No
If yes, please provide the
security controls in place.
7a. Does the Applicant receive money directly from an insurance carrier? Yes No
7b. Does the Applicant have crime coverage in place? Yes No
If yes, what is the limit of liability? $
8. Does the Applicant use a “fee-splittin
g” procedure
when charging providers? Yes No
9. Does the Applicant perform collection services on clients’ p
atien
ts accounts that are over 90 days past due?
Yes No If yes, w
hat percentage of total accounts handled are over 90 days old? %
10. Does the Applicant have HIPAA (Health Insurance Portability and Accountability Act of 19
96) compliance
procedures
in place? Yes No If yes, describe all procedures.
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companie
s Cov
e
r-Pro
sm
application and is subject to the same conditions as stated on the application.
Name (Please Print) Title (Mus
t be Principal, Partner or O
fficer)
__________________________________________
Signature Date
Agent Name Agency Number
Agency Address
PI-PLSP-MBSUPP 08/
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