EmailMe Form - Medical Office Specialist Evaluation (GCC)

What is the Full Name of your Extern? *

First Last

(Please enter the first and last name of your extern, ex. John Smith)

How many Total Days did the Extern Attend? *

(Please enter the number of total days attended, ex. 30)

How many Days was your Extern Absent? *

(Please enter the number days absent, ex. 2)

How many Days was your Extern Tardy? *

(Please enter the number days tardy, ex. 1)

(PLEASE NOTE: A total of 160 hours is required.)

Practical Experience In:

Knowledge of Medical Terminology *

Below Average

Average

Above Average

Excellent

Knowledge of Billing Procedures *

Below Average

Average

Above Average

Excellent

Knowledge of CMS 1500/UB92/Hospital Billing *

Below Average

Average

Above Average

Excellent

Accounts Management Collections (if Applicable)

Below Average

Average

Above Average

Excellent

Coding Ability: ICD-9 *

Below Average

Average

Above Average

Excellent

Coding Ability: CPT *

Below Average

Average

Above Average

Excellent

Coding Ability: Internal/In-House Codes *

Below Average

Average

Above Average

Excellent

Coding Ability: HPCS Codes *

Below Average

Average

Above Average

Excellent

Benefits Verification *

Below Average

Average

Above Average

Excellent

Telephone Skills *

Below Average

Average

Above Average

Excellent

Computer Skills *

Below Average

Average

Above Average

Excellent

Accuracy of Work *

Below Average

Average

Above Average

Excellent

Productivity *

Below Average

Average

Above Average

Excellent

Work Habits and Attitude:

Rapport with Staff and Patients *

Below Average

Average

Above Average

Excellent

Third Party Payers *

Below Average

Average

Above Average

Excellent

Organizational Ability *

Below Average

Average

Above Average

Excellent

Motivation *

Below Average

Average

Above Average

Excellent

Willingness to Learn *

Below Average

Average

Above Average

Excellent

Dependability *

Below Average

Average

Above Average

Excellent

Customer Service *

Below Average

Average

Above Average

Excellent

General Comments:

(Please indicate strong or weak points of this student's performance)

Overall Performance Grade: *

F .

C .

B .

A .

(Please choose a letter grade)

Your Name: *

Prefix First Last Suffix

(Please enter your name, ex. James Brown)

Your Title: *

(Please enter your job title, ex. Supervisor)

Externship Site: *

(Please enter the externship site, ex. St. Joseph's Hospital)

Today's Date: *

MM / DD / YYYY

(Please enter today's date)