Form

MEG Credentialing Services Interest Survey

This form is intended to gather baseline information from practice owners interested in MEG's Credentialing services. After submitting this form, you will be contacted by MEG's Credentialing team to discuss next steps. We look forward to working together!

Owner Information

Practice name*

Email*

First name*

Last name*

Phone number*

Are you a startup?*

Yes

No

If startup, what date did (or will) you open?

Month/Day/Year

If start-up, Where are You at in the Process?

How did you hear about MEG*

Podcast

Found Online

Referral

Other

What Credentialing services are you interested in? (choose all that apply)*

General Practice Information

Street address*

City*

State/Region*

What services do you offer (choose all that apply)*

PT

OT

ST

How many providers do you have on staff?*

What EMR Software are you using?*

What insurances are you currently enrolled in?*

What insurances are you interested in MEG handling?*

Do you offer mobile/home therapy?

YES- in extension to my office location

YES- Mobile Only/ No service location

NO

Additional Information

Please provide any additional notes you would like MEG to know: