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GENERAL PRACTICE INFORMATION:

PHYSICIAN PRACTICE NAME:

PHYSICIAN PRACTICE NAME:

CONTACT PERSON:

PRACTICE ADDRESS:

TELEPHONE NUMBER:

FAX NUMBER:

EMAIL ADDRESS:

# OF PHYSICIANS IN THE PRACTICE:

GENERAL MARKET INFORMATION:

ESTIMATED MARKET MANAGED CARE PENETRATION

  PAYMENT TYPE                                %    

   Fee-for-service         %      

   Discounted FFS         %

   Capitated                    %

ESTIMATED PAYOR MIX OF THE PRACTICE

  MEDICARE                    %

  MEDICAID                     %

  BLUE CROSS                  %

  WORKER'S COMP          %

  HMO/PPO                       %

  CAPITATED                     %

  OTHER INSURANCE         %

  SELF PAY                         %

PRACTICE FINANCIAL INFORMATION:

   PERIOD (INDICATE MONTH/DAY/YEAR)

  MINIMUM 3 MONTHS DATA

NON PHYSICIAN EXPENSES:                                            

 PAYROLL/BENEFITS  $

TOTAL RENT/UTILITIES/TELEPHONE $

MEDICAL SUPPLIES $

OFFICE SUPPLIES $

PROFESSIONAL LIABILITY INSURANCE $  

ALL OTHER EXPENSES $

CPT CODING FREQUENCIES:

PERIOD (INDICATE MONTH/DAY/YEAR)

  MINIMUM 3 MONTHS DATA

   CPT-4            FREQUENCIES                                          FEE

  99201 FEE

  99202 FEE

  99203 FEE

  99204 FEE

  99205 FEE

  99211 FEE

  99212 FEE

  99213 FEE

  99214 FEE

  99215 FEE

  99221 FEE

  99222 FEE

  99223 FEE

  99224 FEE

  99225 FEE

  99231 FEE

  99232 FEE

  99233 FEE

  99234 FEE

  99235 FEE

  99241 FEE

  99242 FEE

  99243 FEE

  99244 FEE

  99245 FEE

  LATEST 12 MONTHS PRACTICE CHARGES

  LATEST 12 MONTHS PRACTICE ADJUSTMENTS

  LATEST 12 MONTHS PRACTICE COLLECTIONS

  CURRENT YTD OVERHEAD PERCENTAGE

  CURRENT ACCOUNTS RECEIVABLE BALANCE   

AGING OF ACCOUNTS RECEIVABLE

         DAYS                            %

  0 - 30 DAYS

  31 - 60 DAYS

  61 - 90 DAYS

  91 - 120 DAYS

  120 + DAYS

  Please allow 5 - 7 working days for Practice Analysis.