Practice Survey

Name

Type of Practice?

Years in Practice?

New Practice?

Practice location: major city or small town?

Office hours?

Number of hours you work?

Number of call days?

Do you also work outside your practice?

Number of employees?

Receptionists

	Check in
	Check out
	Medical Records

Is your billing in-house?
Is your billing out sources?
Do you use paper claims?
Do you use electronic claims?
Is insurance verification done by phone?
Is insurance verification done online?

	Entering charges, Posting charges
	Collections

Back Office

	Medical Assistants
	Nurses
	PA
	NP
	MD

Expenses- you may attach expense statement from accountant

	Monthly lease or mortgage payment
	Monthly malpractice payment
	Business loans
	Retirement plan expanses
	Equipment lease payments
	Furniture payments
	Medical Supplies
	Monthly Payroll expenses (Itemized)
	Office supplies
	Health insurance and other employee benefit expenses
	Professional fees
	Accountant fees
	Legal fees
	Advertising
	Education (CME expenses)
	Other Expenses

Number of patients seen per day?

Average time patients are seen?

Please attach a summary of frequency of CPT codes billed

How often do you bill new patient codes?

99202

99203

99204

99205

How often do you bill established patient codes?

99212

99213

99214

99215

How many surgery or procedure cases do you perform each month?

What is the usual reimbursement for these surgeries and procedures?

Average monthly practice gross income?

Monthly income from supplements or product sales?

Are you happy with the type of medicine that you are presently practicing? If no, please describe your ideal practice.

Please describe your practice philosophy?

Please list what you like the most about your practice.

Please list what you like least about your practice.

What would you like to change about your life outside your practice?

What would you do if you had more free time?

What would you do if you had more money to spend in your free time?

What is more important to you more time, more money or both?

Are you interested in implementing BHRT and saliva testing in your practice?

Are you interested in introducing cosmetic procedures in your practice?

Are you interested in introducing weight loss to your practice?

How stressful is your life?

How much stress does your practice contribute to your life?

Have you thought about getting out of medicine or closing your practice?

Does your practice interfere with your personal happiness?

Have you ever missed a paycheck?

Have you ever had to use your personal money to cover office expenses?

At what age would you like to retire?

What retirement vehicles do you have in place? i.e. Real estate, IRAs, stocks, saving account, or whole life insurance.

Do you have a clear asset protection plan or strategy?

Comments(Anything else you would like us to know?)

Physician’sName

Business Address

Phone number
Business:

Phone number
Cell:

E-mail

Please complete and email back to us at maxhealthed@yahoo.com
Or fax to 678-443-4090

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