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ASC Questionnaire
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Practice Name
*
Address
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Telephone
Fax
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Lead Physician
*
Telephone
Cell
*
Email
Due Diligence Contact – Person who can assist with obtaining information
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Name / Title
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Telephone
*
Email
Fax
PHYSICIANS ASSOCIATED WITH PRACTICE
Name
# Years Left to Practice
Board Certified
Specialty
1
N/A
Yes
No
2
N/A
Yes
No
3
N/A
Yes
No
4
N/A
Yes
No
5
N/A
Yes
No
6
N/A
Yes
No
7
N/A
Yes
No
HISTORICAL PROCEDURE VOLUMES
Please provide an estimate of your annual volumes or each of these procedures.
Colonoscopy
EGD
Please list the names of the facilities where you perform procedures and an estimate of your group's annual outpatient volumes for each facility.
Facility Name
% Procedures
% ASC
1
2
3
What is the cost for medical grade space per sq ft?
HOURLY SALARY RATES
for Non Physician Staff
RN
LPN
Medical Tech
Medical Assistant
Receptionist
PAYOR MIX
Estimate of your practice payor mix (based on collected revenue)
Medicare
Medicade
BCBS
Aetna
Other