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To better determine how OMS can improve your practice, please answer the following Practice Profile Questionnaire. This will provide information to better understand your practice characteristics and needs.


All fields in bold are required.

First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone Number:
Email:

Practice name
Do you own your practice?
If you do not own your practice, are you an employee of a private optometric or ophthalmology practice? (Answer NA if not applicable.)
Describe your office physical plant ( free-standing building, shopping center, professional building )
Are you located next to a corporate retailer?
How long have you been in practice?
Please list medical diagnostic equipment you currently use in your practice.
How many ECP's are in your practice?
Are any of the doctors residency trained?
Do you currently have a dedicated medical billing and coding person?
What percent of your total revenue is from (must total 100%):
Optical & Contact Lens Routine Exams (Vision) Medical Exams
Annual Gross Volume of your Practice
How many routine vision exams do you perform in a day?
How many medical exams to you perform in a day?
How many contact lens related visits do you see in a day?
Do you run an Aged Accounts Insurance Receivables Report monthly and review? (30, 60, 90, 120+ report)?
Do you run an Aged Accounts Patient Receivables Report monthly and review? (30, 60, 90, 120+ report)?
Do you mail patient statements for past due account balances?
List the medical plans you are currently a provider for.
List the vision plans you are currently a provider for.
Are you on an EMR system? If yes, which one?
Are you participating in Meaningful Use, PQRS, ePrescribing?
Do you have a Compliance Plan in place?
Additional Comments:
What is 7+2?