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Form Test
Practice Name
Practice Manager Name
*
Email
*
Phone
Practice Address
Street Address
City
State
Zip Code
Current Payor Mix
Payor
*
% PPO
*
% HMO
*
In or Out of Network
*
In
Out
% of Patients by Payors
*
Please enter a number less than or equal to
100
.
Payor
*
% PPO
*
% HMO
*
In or Out of Network
*
In
Out
% of Patients by Payors
*
Please enter a number less than or equal to
100
.
Payor
% PPO
% HMO
In or Out of Network
In
Out
% of Patients by Payors
Please enter a number less than or equal to
100
.
Payor
% PPO
% HMO
In or Out of Network
In
Out
% of Patients by Payors
Please enter a number less than or equal to
100
.
Payor
% PPO
% HMO
In or Out of Network
In
Out
% of Patients by Payors
Please enter a number less than or equal to
100
.
Payor
% PPO
% HMO
In or Out of Network
In
Out
% of Patients by Payors
Please enter a number less than or equal to
100
.
Who will be placing the electrodes on the patients? (MA, PA, RN, or LPN)
*
MA
PA
RN
LPN
Other
Will preauthorizations be done in-house or by Biowave?
*
In-House
Biowave
