ASC Questionnaire

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Due Diligence Contact – Person who can assist with obtaining information

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PHYSICIANS ASSOCIATED WITH PRACTICE
HISTORICAL PROCEDURE VOLUMES
Please provide an estimate of your annual volumes or each of these procedures.


Please list the names of the facilities where you perform procedures and an estimate of your group's annual outpatient volumes for each facility.


HOURLY SALARY RATES
for Non Physician Staff
PAYOR MIX
Estimate of your practice payor mix (based on collected revenue)