Pre-Training Assessment Form : ERN Enterprises, Inc.

Your Order Number (Your order number is located in your emailed order receipt.)

Your Email (Please enter the email that you used to purchase your training.)

PROVIDER INFORMATION

Provider Name

Contact Phone Number

Contact Email (If you wish future correspondence to go to another email, you may enter it here.)

DESIRED SCHEDULING

Name of training venue

Training venue physical address

Training event date

Training event time

AUDIO/VISUAL EQUIPMENT REQUEST

Please indicate whether you can provide any of the following equipment

TV Screen/Monitor (for use with PowerPoint Presentations)

YES

NO

Brand

Size

Ports

LCD Projector (for use with PowerPoint Presentations)

YES

Option 2

Projector Screen

YES

Option 2

Internet Connection

YES

Option 2

Wi-Fi

YES

Option 2

Ethernet

YES

Option 2

Podium

YES

Option 2

Lapel Microphone

YES

Option 2

Handheld Microphone

YES

Option 2

PROVIDER’S STAFF

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

How many PFS reps do you have?

How many Managers/Supervisors?

What is your payor mix?

(For each number field, enter a percentage.)

Managed Care (%)

Worker’s Compensation (%)

Medicare/Medi-Cal (%)

Third Party Payors/Indemnity Carriers (%)

Plan Administrators (%)

Veterans Affairs (%)

Other (%)

What % of your monthly goal have you hit for the past 3 months?

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.

Issue 1