CMW New Provider Interest Questionnaire

We would love to get a little more information from you about your practice and the services that you are needing. Please complete the questionnaire & provide any additional pertinent information. We have also included information about Commonwealth Medical Billing, LLC, what we offer and our fees. Please let us know if you have any questions and would like to move forward. We look forward to hearing from you!

Question Title

* Provider Info

Name *

Office Name

Address *

City *

State *

ZIP *

Email Address *

Phone Number *

Question Title

* Your Credentials

LCPC

LCSW

LPC

LPCC

LMHC

MFT

MHC

PMHNP

Other (Please Specify)

Question Title

* What services are you interested in today?

Credentialing Services

Hourly Consultation

One Time Practice Set-Up

Full Practice Management(Billing, Posting, Denials, Verifications, ERA,EFT Set-Up)

Other (Please Specify)