Pre-Training Assessment Form

Seminar Facilitator: Ed Norwood, Chief Compliance Officer
Organization: ERN/The National Council of Reimbursement Advocacy Firm
Address: 5856 Corporate Ave., Suite 110
City, State, Zip: Cypress, CA 90630

* = required


PROVIDER INFORMATION



DESIRED SCHEDULING



AUDIO/VISUAL EQUIPMENT REQUEST

PLEASE INDICATE WHETHER YOU CAN PROVIDE ANY OF THE FOLLOWING EQUIPMENT





















PROVIDER'S STAFF

To help us keep the flow of your seminar smooth in the time frame allotted, please answer the following questions.


What is your payor mix?








TOP 5 ISSUES

What are your top 5 payor issues/denials (e.g. ER services denied as not medically necessary or unauthorized; underpayments, claim delays, timely filing requirements)? Briefly describe your method or strategy for dealing with each issue. Please include payor type.