Boundless Essentials, LLC - FORM | GEN | Prospective Client Inquiry

boundless essentials

For Therapists. By Therapists.

Tell us a little about your practice and what kind of support you're looking for.

This form is intentionally brief—we just need enough information to understand how Boundless Essentials might be able to help.

Company Name*

WHAT IS THE NAME OF YOUR PRIVATE PRACTICE?

Website

First Name*

Last Name*

Primary Phone*

Primary Email*

Which option best describes your practice or organization?*

How many active rendering providers currently work within the practice?*

In what state(s) does your practice operate?*

PLEASE SELECT ALL THAT APPLY

How can we help? Select the service(s) you are interested in.*

PLEASE SELECT ALL THAT APPLY

Monthly Bookkeeping

Bookkeeping Clean-Up / Catch-Up

Insurance Billing & Revenue Cycle Management (RCM)

Insurance Claim Clean-Up / Catch-Up

Insurance Credentialing

Not Sure Yet

Who has primarily maintained the financial records for your Practice?

Approximately how many accounts require reconciliation?

Examples may include checking and savings accounts, business credit cards, lines of credit or loans, etc.

Do you have other revenue streams for your Practice outside of traditional therapy services?

Examples may include supervision or consultation fees, training/workshops, speaking engagements, courses or educational products, etc.

Yes

How many payers are you currently paneled with?

What is your current enrollment status for Electronic Remittance Advice (ERA) and Electronic Fund Transfer (EFT) for paneled insurances?

PLEASE SELECT ALL THAT APPLY

How did you hear about Boundless Essentials?*

PLEASE SELECT ALL THAT APPLY

Referral from a Colleague or Another Practice Owner

Google / Search Engine / Website

Social Media

Networking Event

Returning / Previous Boundless Essentials Client