| CONTACT
INFORMATION |
|
| Member's
Name |
|
| Practice
Name |
|
| Number
of Locations |
|
| Primary
Practice Address |
|
| Telephone |
|
| Fax |
|
| Email |
|
| MEMBER
INFORMATION |
|
| Professional
Licenses / Certifications |
|
| University
Degrees / Where |
|
| Years
as Therapist |
|
| Years
in Business |
|
| Years
at Same Location |
|
| PRACTICE
SITE INFORMATION |
|
| Type
of Entity - Corporation, etc. |
|
| Number
& % Ownership of Partners |
|
| Facility
Size in Square Feet |
|
| Number
of Employees |
|
| Benefits
Package |
|
| Employee
#'s by PT's, PTA's, OT's, CHT's, Aides, Admin., etc. |
|
| Programs
Offered - Aquatic, Pediatric, Hand, etc. |
|
| Medicare
Certification & Type - Rehab Agency? |
|
| Networks
- PTPA, PTPN or Other |
|
| Brief
Description of Network |
|
| What
Professional Publications do You Receive? |
|
| Description
of Major Referral Sources |
|
| HIGHLY
CONFIDENTIAL - Key Financial Relationships? |
|
| Strategic
Relationships With Hospitals & Therapists? |
|
| MORE
PRACTICE INFORMATION |
|
| New
Patient % - Medicare, Indemnity, PPO, Work Comp, HMO |
|
| New
Patients Per Week by Facility |
|
| Patient
Visits Per Week by Facility |
|
| Average
Wait for Evaluation |
|
| Average
Time in Waiting Room |
|
| No
Show & Cancel % New Patients |
|
| No
Show & Cancel % Daily Visits |
|
| Policy
for No Show & Cancel Follow-up |
|
| Other
Patient Compliance Efforts |
|
| Patient
Education Programs |
|
| Corporate
Programs |
|
| Community
Service Programs |
|
| FINANCIAL
INFORMATION |
|
| Billing
In House or Service - If Service % Cost |
|
| Average
Charge Per Visit - YTD, Last Month, Last Year |
|
| Average
Collect Per Visit - YTD, Last Month, Last Year |
|
| Number
of Visits - YTD, Last Month, Last Year |
|
| Current
Accounts Receivable |
|
| Accounts
Receivable - YTD, Last Month, Last Year |
|
| Visits
by Type - YTD, Last Month, Last Year - Medicare, Indemnity,
PPO, Work Comp, HMO |
|
| %
Billed by Type - Medicare, Indemnity, PPO, Work Comp,
HMO |
|
| %
Cash by Type - Medicare, Indemnity, PPO, Work Comp, HMO |
|
| MARKETING |
|
| Briefly
Describe Your Market |
|
| How
Do You Rank in Your Market? |
|
| Consultants
Used & $'s Spent - YTD, Last Month, Last Year |
|
| Overview
of Program |
|
| Statistical
Follow-up Methods |
|
| Scheduled
Contacts |
|
| Type
& % of Contacts - Mail, Visits, Email, etc. |
|
| Do
You Use Patient Satisfaction Surveys? |
|
| Do
You Use Physician Satisfaction Surveys? |
|
| Do
You Keep a Database on New Patients Referred? |
|
| Do
You Have a Website? |
|
| What
is it's Goal & Scope? |
|
| What
Have Been Your Most Successful Marketing Tools? |
|
| What
Have Been Your Least Successful Marketing Tools? |
|
| COMPETITION |
|
| Who
is Your Biggest Competition? |
|
| Why
Do You Feel They Are Successful? |
|
| Do
You Think You Can Compete? |
|
| What
is Their Biggest Strength & Weakness? |
|
| What
is YOUR Biggest Strength & Weakness? |
|
