BreezyBilling New Customer Questionnaire

BreezyBilling Setup Form

Let's get started!

First, we'll need to know all of your Primary Contacts. These are owners, decision-makers or administrators who are allowed make decisions or changes related to the services and software.

You will need the following information to complete this form:

  • Practice Details including Address(es), EIN and NPI 
  • Provider and User information including NPIs and license information
  • Charges for billing codes
  • Insurances Accepted
Are you a Primary Contact?
The Primary Contact generally has full access to BreezyNotes and all reporting as well as the ability to make decisions and request changes to the software or billing processes. Typically Primary Contacts are owners or administrators involved in the day-to-day operations of the practice.

Unfortunately, this form can only be completed by someone at the practice who is approved to make decisions for the practice. Please contact your sales representative to continue.

Your Contact Info

If there are additional Primary Contacts at your practice, they can be added further down the form in the "Enter User(s) Details" section.

Practice Information

Primary Practice Location
Primary Practice Location
Additional Facilities?
Great! For security purposes, we will collect your SSN during your training call.
No Facility NPI? No worries! We'll get your Individual NPI later. Not sure what kind of NPI you have? Click here to look it up!

Additional Facilities

Primary Practice Location
Primary Practice Location
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Please indicate which services your clinic offers:

CPT Billing Codes

Please list what you charge for the following codes. Leave the amount blank for any code you do not want included.
Include Code, Description and Amount

Private Pay Codes

Please list what you charge for the following Private Pay codes:
Enter any dollar amounts you'd like to be able to charge clients. These codes can always be amended later.

Insurance Accepted

For your convenience we can preload your practice's insurance data. Enter the names of the insurance companies you contract with, and we will have them ready for you when you first log in.
Are you a Medicare Provider?
Medicare is the federal health insurance program typically for individuals over the age of 65.
Individual PTANs will be entered along with other individual provider information.

Insurance Companies Accepted (In Network)

List only insurance companies with whom you or your practice have an active contract (one per line).
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Insurance Companies Accepted (Out of Network)

List only insurance companies you submit claims to that you are out of network with (one per line).
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Primary Contact - Additional Information

Your PTAN, or Provider Transaction Access Number, is the number assigned to Medicare-enrolled providers. If you are not a Medicare provider, leave this blank. If you do not know your PTAN or are unsure please put "Unknown."
If you are unsure of your NPI, license number or Taxonomy Code, you can look up this information in the NPPES.
Paper checks get lost. At no extra cost, Breezy will set up direct deposit (aka EFT or ACH) with all of your payers so funds are deposited into your bank account.
Appointment Reminders
Check here if you'd like the ability to send your clients text message appointment reminders ($0.10/reminder).
Would you like to take credit card payments from clients?
You can keep client credit cards on file, and if you include our Client Portal, clients can pay you directly..
Do you have a Stripe Account?
We use a tool called Stripe to process credit card payments securely and in compliance with PCI-DSS standards. If you don't have one, we will help you set it up.
Client Portal
Clients can complete intake paperwork, message providers, schedule appointments and pay bills. $20/month for unlimited clients.
Select "Yes" to set up accounts for other providers at your practice or people who need access to your instance of BreezyNotes.

Enter User(s) Details

This email will be assigned to the user account and used for password resets and messages.
Your PTAN, or Provider Transaction Access Number, is the number assigned to Medicare-enrolled providers. If you are not a Medicare provider, leave this blank. If you do not know your PTAN or are unsure please put "Unknown."
This user should also be considered a Primary Contact.
Primary Contacts are defaulted with full access to BreezyNotes and all reporting as well as the ability to make decisions and request changes to the software or billing processes. Typically Primary Contacts are owners or anyone involved in the day-to-day operations of the practice.
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