YOUR INFO:* Required Field


ALLYNE ID#:

* Company Name:

* First Name:

* Last Name:

* Email:

Office Phone:

* Mobile Phone:

Referrer Comments:



PROSPECTIVE SURGERY CENTER INFO:

Contact Information


* Center Name:

* Website:

Street Address:

* City:

* State:



* Contact First Name:

* Contact Last Name:

Contact Title:

Email:

Phone:

Mobile:


Center Information

Facility Type:

# Procedure Rooms:

# Operating Rooms:

# Room(s) Open Per Day (M-F):

# Room(s) Avg Hours per Day:

Annual # of Patients Treated at Center:

% of Endoscopy cases having double Procedures:


Current Status

Who Owns Anesthesia Provider?:

# of Anesthesiologists:

# of CRNAs:

New Agreement Start Date:


Annual Case Volume By Type

General:
Cardio Thoracic:
ENT:
Gynecology:
Neurology:
OB – Epidurals / C-Sections:
Ophthalmology:
Orthopedic:
Urology:
Vascular:
Other:
Pain Management:
Podiatry:
Endocrinology:


Annual Case Volume % By Payors

Aetna:
BCBS PPO:
BCBS Other:
Champus:
Cigna:
Commercial:
Free Clinic:
HMO:
Humana:
Medicaid:
Medicare:
Personal Injury / Auto:
Replacement Plan:
Self Pay:
United Healthcare:
Workers' Comp:
Other:



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