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CONFIDENTIAL

Quick and Dirty HIPAA Administrative Simplification Benefit Calculation Estimator

 Instructions and Demographic Information  

Organization Name:                                                                                                 

City:                                                                State:                                               

E-Mail:                                                           

Type:

Medical Group

Multispecialty
Single Specialty_____________________________________

Solo or Two Physician Practice        

Hospital

One Hospital
Multiple Hospital – Number _________        

Other 

Size:           

Number of Physicians                                                          (FTE)           

Annual Gross Revenue                     $                                  (Last fiscal year) 

Do you submit electronic claims now?

Medicare only           
Most payers           
Only submit payer claims           
Other                                                                                                  

Do you use a clearinghouse?           

Yes (company)                                                                                             
No  

Fax forms on pages 1 and 2 to: 

Steven S. Lazarus
Boundary Information Group
(303) 488-9911 Phone, (303) 488-9994 FAX