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U.S. Bank Request for Information Form.

Yes! I would like more information on how U.S. Bank Healthcare Payment Management can help me increase collections at the point of service, reduce bad debt, and improve the patient experience. Please have a U.S. Bank representative contact me to set up an online product demonstration.

NAME
TITLE
PRACTICE
TELEPHONE
EMAIL ADDRESS
  I prefer that you contact me by:
 telephone
 email
  Do you currently accept these forms of payment? (check all that apply):
 Credit Cards
 Visa Cards
 MasterCard
 Discover
 Checks
  If yes, what is your average monthly credit card volume?
  How many locations do you have?
  At how many of them do you process payments?
  Do you verify patient insurance eligibility?
 Yes
 No
  How do you verify eligibility?(check all that apply)
 Phone   Web   Other 
  Do you offer your patients payment plans (installment plans)?
 Yes
 No
  Do you print and/or mail your own patient statements?
 Yes
 No
  What practice management system do you use?
  Who is your current clearinghouse?
  What is your timeline for implementing HPM?
 0-1 month
 2-5 months
 6+ months
 

 




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