AER CONSULTING, INC.
Attachments
NAME OP PRACTICE:___________________________________________________
Dr.CVs
Name of provider: __________________________________________________
ADDRESS:_____________________________PH:____________Fax:____________
E-Mail
Address _____________________________________________________
OFFICE HOURS:_______________________________________________________
BUILDING:
Owner_______ Leased________ Other ______________________
SERVICES:
OP SURGERY______ In HOUSE LAB________ DME:_________ Productivity
IN HOUSE X-RAY___________ OTHER_________________________ Report
ACCOUNTANT:_______________________________________________________
Name
Address Phone/Fax #s
ATTORNEY__________________________________________________________
Name
Address
Phone/Fax #s
PERSONNEL: Doctors___________Nurses_________ Managers________
List of Staff
Technicians:_________ Lab_________ X-Ray_________
Name,DOE,Hrs
Office___________ Other__________________________
Salary
Total Staff:________________________
YEAR-TO-DATE LAST YEAR
Monthly
STATISTICS: Patients
seen per month ____________ ____________
Breakdown
Patient Mix: Private Pay_________
ATTACH List
HMO _________
PPO _________
Medicare _________
Medicaid _________
Contracts _________
Other _________
Referral Sources
Tracking Rpt.
Average Number
of New Patients
per Month ____________
_____________
Number of Active Patients
____________ _____________
Monthly Charges (average)
____________ _____________ SystemSummary
Monthly
Collections (Average) ____________ _____________
Insurance Forms Processed/month ____________
_____________ Ins.Aging Sum
A/R
% patients insurance verified prior to visit _______________
% patients co-pay collected at time of visit _______________
% patients deductibles collected at visit _______________
Managed
Care Participation - # of Plans ________________________ List of Plans
Collection
system in use ________________________
Aging Rpt Sum
Do you use a billing service Yes
No
Agreement
If yes, NAME ____________________________
Date
of contract_________________________
Monthly Expenses
Financial St
Doctor Salaries
2 years
Staff Salaries
Operating expenses
Loans Outstanding
Amount/Source
COMPUTER SYSTEM: Hardware________________________
Software________________________
Electronic Billing Y N
Appointments Y N
Word Processing Y N
Medical Records Y N
Collection System Y N
ORGANIZATION:
PA________ Solo_______ Corporation _________
Mission Statement Y
N
ATTACH
Goals/Objectives
Y N
ATTACH
Organizational Chart
Y N
ATTACH
Personnel Manual
Y N ATTACH
Procedure Manual Y
N
ATTACH
Job Descriptions
Y N
ATTACH
New Employees Oriented
Y N
Continuing Training
Y N
MARKETING:
Advertising Y
N YP Newsltrs
Media
Fairs Other
Patient Satisfaction Ques. Y N
ATTACH
Focus Groups
Y N
Practice Brochure Y
N
ATTACH
Patient Info Brochure
Y N
ATTACH
Logo
Y N
Newsletter
Y N
ATTACH
Seminars/Speakers Bureau Y N
Tracking Systems Y
N Referrals Other
INSURANCE :
General Liability Y
N Limits
Professional Liability
Y N Limits
Automobile
Y N Limits
Umbrella
Y N Limits
Workers Corp
Y N
Comprehensive Ins.
Y N Fire,burglary,,.
Fidelity Bond (employee) Y N Amount-$______________
Multi-peril Package Y
N Covers all except WC.?
Health Insurance
Y N Type
Disability Insurance
Y N Who
Overhead Insurance
Y N Who
PROBLEMS:_________________________________________________________________________
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FUTURE
GROWTH:____________________________________________________________________
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OTHER
COMMENTS:___________________________________________________________________
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Date:
______________Completed By: _______________________________________________
Name and title
AER CONSULTING, INC.
P. O. BOX 320245, TAMPA, FLORIDA 33679-2245
