Testing New Client Form

I am a new...*

Billing Client
Coding Client

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Coding Type*

Home Health
Hospice
Both

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Coding Services

Coding
Coding & OASIS Review

Agency NPI:*

Tell Us About Your Organization

Please ensure the following agency information is accurate and complete.

Agency Name*

DBA if applicable

Phone*

Fax #

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Alliance Owner

Alliance Contact Name*

First Last

Alliance Contact Title

Alliance Contact Phone*

Alliance Contact Phone Ext.

Alliance Contact Email*

Invoicing Communications Contact

Invoicing Contact Name

First Last

Invoicing Contact Title

Invoicing Contact Phone

Invoicing Contact Phone Ext.

Invoicing Contact Email

Billing Contact

Billing Contact Name

First Last

Billing Contact Title

Billing Contact Phone

Billing Contact Phone Ext.

Billing Contact Email

Clinical Contact

Clinical Contact Name

First Last

Clinical Contact Title

Clinical Contact Phone

Clinical Contact Phone Ext.

Clinical Contact Email

Coding Contact

Coding Contact Name

First Last

Coding Contact Title

Coding Contact Phone

Coding Contact Phone Ext.

Coding Contact Email

Managed Care Consulting Contact

Managed Care Contact Name

First Last

Managed Care Contact Title

Managed Care Contact Phone

Managed Care Contact Phone Ext.

Managed Care Contact Email

Portal Administrator Contact

Portal Administrator Name

First Last

Portal Administrator Title

Portal Administrator Email

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Do you bill Medicare for services?*

Yes
No

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Medicare PTAN:

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Taxonomy #

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Organization Tax ID:*

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Will We Be Billing Home Health or Hospice Services?*

Home Health
Hospice
Both

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Will We Be Providing Clinical Services for Home Health or Hospice?*

Home Health
Hospice
Both

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Will We Be Providing Billing or Clinical Consulting?*

Billing
Clinical
Financial

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Will We Be Providing Billing Consulting Services for Home Health or Hospice?*

Home Health
Hospice

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Will We Be Providing Financial Consulting Services for Home Health or Hospice?*

Home Health
Hospice

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Will We Be Providing Clinical Consulting Services for Home Health or Hospice?*

Home Health
Hospice

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Please mark all services we will be providing:

Coding
OASIS

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Use email communications contact

Use email communications contact

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Authorized Medicare Official*

First Last

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Authorized Medicare Official Title

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Authorized Medicare Official Email*

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Use email communications contact

Use email communications contact

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Use primary billing contact

Use primary billing contact

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Use email communications contact

Use email communications contact

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Use primary billing contact

Use primary billing contact

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Use primary clinical contact

Use primary clinical contact

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Use email communications contact

Use email communications contact

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Use email communications contact

Use email communications contact

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Use primary billing contact

Use primary billing contact

EMR Software

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What electronic medical record (EMR) software system is utilized in your agency?*

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Please enter any other medical record (EMR) software that's utilized in your agency (if applicable)

HPS ShareFile

To remain HIPAA compliant, we will exchange patient health information securely via our HPS ShareFile system. In order to access this system please indicate up to three users who will require access to each of these folder(s).

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Use primary billing contact

Use primary billing contact

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Billing Communications - Name*

First Last

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Billing Communications - Email*

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Billing Communications 2 - Name (Optional)

First Last

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Billing Communications 2 - Email (Optional)

Coding Communications Folder

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Use primary coding contact

Use primary coding contact

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Coding Communications - Name*

First Last

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Coding Communications - Email*

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Coding Communications 2 - Name (Optional)

First Last

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Coding Communications 2 - Email (Optional)

Clinical Communications Folder

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Use primary clinical contact

Use primary clinical contact

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Clinical Communications - Name*

First Last

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Clinical Communications - Email*

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Clinical Communications 2 - Name (Optional)

First Last

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Clinical Communications 2 - Email (Optional)

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Clinical Communications 3 - Name (Optional)

First Last

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Clinical Communications 3 - Email (Optional)

Weekly Billing Summary Folder

HPS will send weekly billing activity summary reports via Sharefile. Please identify the individuals who will need access to this information (typically management or oversight personnel) Please provide up to 3 users, first and last name and e-mail addresses of individuals who will need access to this folder.

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Use primary billing contact

Use primary billing contact

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Billing Summary - Name*

First Last

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Billing Summary - Email*

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Billing Summary 2 - Name (Optional)

First Last

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Billing Summary 2 - Email (Optional)

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Billing Summary 3 - Name (Optional)

First Last

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Billing Summary 3 - Email (Optional)

Overdue Claims Reporting Folder

HPS will send monthly detailed AR status reports reports via Sharefile. Please identify the individuals who will need access to this information (typically management or oversight personnel) Please provide up to 3 users, first and last name and e-mail addresses of individuals who will need access to this folder.

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Use primary billing contact

Use primary billing contact

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Overdue Claims - Name*

Jane Doe

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Overdue Claims - Email*

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Overdue Claims 2 - Name (Optional)

First Last

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Overdue Claims 2 - Email (Optional)

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Overdue Claims 3 - Name (Optional)

First Last

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Overdue Claims 3 - Email (Optional)

Managed Care Consulting Folder

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Use email communications contact

Use email communications contact

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Managed Care Communications - Name*

First Last

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Managed Care Communications - Email*

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Managed Care Communications 2 - Name

First Last

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Managed Care Communications 2 - Email

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Managed Care Communications 3 - Name

First Last

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Managed Care Communications 3 - Email

Agree to Terms

It is your responsibility to notify HPS immediately should one of the staff members listed above need to be removed from this communication channel. Please sign below indicating your acknowledgment of this responsibility.

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Electronic Signature*

Regulatory Compliance Visit

To add value to the billing relationship and to assist in ensuring regulatory compliance once per year an HPS staff member will come on-site to your agency to perform a clinical compliance chart review on a sample of claims billed in the last 12 months. Please identify, providing name, phone number and e-mail address, the person within your organization with whom we should coordinate this annual visit:

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Use primary billing contact

Use primary billing contact

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Use primary clinical contact

Use primary clinical contact

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Use primary coding contact

Use primary coding contact

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Regulatory Compliance Contact Name*

First Last

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Regulatory Compliance Contact Title

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Regulatory Compliance Contact Email*

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Regulatory Compliance Contact Phone*

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Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code