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?
* Required Field