Advanced Healthcare Solutions

Client Order Form

Please fill out form to the best of your knowledge so that we may locate the ideal candidate for your practice.


Client Order Form
Name of Client:
Client Address:
Billing Address
Medical Specialty:
Contact Name & Title:
Phone Number:
Back Line and/or Cell:
Fax Number:
Email:
Positions:
Position You Wish To Fill:
Type of Placement
Pay Range:
Length of Assignment:
Job Duties: Vitals Injections Immunizations Height/Weight Growth Charts Blood Pressure (Manaual or Digital) A/R Reports Appeals Denials Phones/Faxing/Copying Adjustments Refunds Processing checks Typing Insurance Verifications Referrals/Authorizations Setting Appointments Collecting Copays Patient Collections Rx Refills Pulling Medical Records Rooming Patients Data Entry Drug Screens Physicals Suture Removal Assisting doctor with minor procedures Prepping rooms for examination Bilingual UA Casting/Splinting Audiology Well Women Exams Well Child Exams Case Management Other
Duties Not Listed:
Software System:
Patients/Accounts Per Day:
Days:
Hours:
Number of Doctors:
Start Date
Additional information about Client/Job: