* Contact First Name:

* Contact Last Name:

* Contact's Credential --OR-- Title:

Other Title:

* Practice Name:

* # 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?

Ancillary Services
Do You Currently Offer Any of the Following?
Please Check All That Apply

Allergy Testing Treatment# Allergy Tests Treatment - per month:
ASC# Cases - per month:
Cognitive and Balance Assessment# Cognitive and Balance Assessment - per month:
Compound Pharmacy# Compound Pharmacy - per month:
DME# DME - per month:
Electrodiagnostics# Electrodiagnostics - per month:
Genetic Testing# Genetic Testing - per month:
Home Health# Home Health - per month:
Imaging# Imaging - per month:
Molecular Testing# Molecular Testing - per month:
Pathology# Pathology - per month:
Pharmacogenetic Testing# Pharmacogenetic Testing - per month:
Physical Therapy# Physical Therapy - per month:
Prosthetic Devices and Supplies# Prosthetic Devices and Supp - per month:
Radiation Therapy# Radiation Therapy - per month:
Rehabilitation# Rehabilitation - per month:
Sleep Testing# Sleep Testing - per month:
Specialized Blood Tests# Blood Tests - per month:
Toxicology# Toxicology - per month:
OTHER# OTHER - per month:

* 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