Contact First Name:
Contact Last Name:
Contact's Credential --OR-- Title:
# Physicians in Group:
Please Enter the Number of Physicians in your Group
# of Practice Locations:
Annual Prof Services Revenue:
What is the Approximate Annual Professional Service Revenue for the Total Practice?
Monthly Unique Patient Visits:
What is the Approximate Number of Unique Patient Visits per Month?
Monthly New Patient Visits:
What is the Approximate Number of New Patient Vists Per Month?
What % of Professional Services are Reimbursed by Federal Payors?:
(Includes Medicare, Medicaid, Tricare, Blue Cross Federal)
What % of Professional Services are Reimbursed by Managed Care Organizations?
Do You Currently Offer Any of the Following?
Please Check All That Apply
Does the practice or the physician have any Surgery Center ownership?
If you are part of a group, can you pick your own service providers?
Cost Savings Assessment
Please answer the following questions regarding your Practice:
Are you currently using a GPO?:
If so, from which one?:
From which distributor(s) do you currently purchase your medical supplies?:
Please provide the following information on a separate attachment:
1) Vendor list and associated spend by vendor for the last 12 months
2) 3 and 12 month supply purchase history, including medical supply, pharmaceutical supply and laboratory supply spend
For instructions on how to download various distributors’ information please see links below:
Once the information in step 2 is complete, please email to Amerinet@allynehealth.com with the practice name in the subject line. If you have any questions, please call Curt Merriweather from Amerinet at 678-381-7488.
* Required Field