New Client Assessment Form-Healthcare Provider

Full Name *

First Name Middle Name Last Name

Birth Date *

Month Day Year

Home Address *

Phone Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

example@example.com

Years in profession?

Professional Memberships?

Name of Company *

Address of Company *

Phone Number *

Area Code Phone Number

Fax Number *

Area Code Phone Number

List type of practice *

website *

Number of years at present location? *

Number of Owners for current location? *

List your hours of operation *

Do you own more than 1 location ? *

List other businesses that you have ownership in *

Where do most of your customers come from now? *

Do you provide vaccination services? *

What other services would you like to provide? *

N/A if not applicable

What other services would you like to provide? *

N/A if not applicable

Who is the EMR service provider? *

What other software providers does the practice use? *

Who is the internet service provider? *

Do you have IT support? If yes, list service provider *

If no, would you need IT service provider recommendation? *

How many drug suppliers does the pharmacy have? *

Name of primary pharmacy drug supplier? *

List other services your primary pharmacy drug supplier bills you for monthly? *

Does your primary supplier provide vitamins?

Does your primary supplier provide herbal products?

Does your primary supplier provide OTC?

Do you perform safety inspections of your facilities?

If the answer to the above question is yes, how often? *

Is your facility professionally cleaned?

If the answer to the above question is yes, how often? *

How many staff members do you have? *

Do you offer staff bonuses? *

If the answer to the above question is yes, what is the criteria? *

Do you have an employee manual or hand book? *

Do you offer any employee benefits? *

If the answer to the above question is yes, what is employee benefits are offered? *

Do you require employees to sign a noncompete? *

Do you have a dress code? *

Do you have written procedures for workflow and operations? *

If the answer to the above question is yes, provide a recent copy here:

Browse Files

How are messages relayed to practice MDs or practioners? *

What is your standard telephone answering process? *

Example: Thank you for calling pharmacy 45 this is X how may I serve?

What is your after hours phone messaging process? *

Are there regular staff meeting? *

yes or no

If the answer to the above question is yes, what is covered? *

Is there someone responsible for checking and sorting mail for manager/owner? If yes insert name and title *

Is there someone responsible for patient problem follow ups? If yes insert name and title *

Is there someone responsible for tracking & reporting Quality Measures for MACRA or MIPs? If yes insert name and title *

Would you like assistance with tracking & reporting Quality Measures for MACRA or MIPs? *

What is the policy for patient problem follow ups? *

On average how long does it take for your practice to follow up with patient concerns? *

What is the policy for patient complaints? *

Is there someone responsible for medication therapy management? If yes insert name and title *

What is the policy for patient refills? *

How long does your practice take to process patient refills? *

Is there someone responsible for sorting and reviewing faxes from doctor's offices or hospitals? If yes insert name and title *

Is there someone responsible for processing referrals? If yes insert name and title *

What is the process for sending & receiving referrals? *

Is there someone responsible for sorting and reviewing lab reports? If yes insert name and title *

How are abnormal lab results handled? *

Do you provide diabetes education or other clinical education services to the ageing communities? *

Yes or No

List the clinical education services you provide to the ageing community? *

List the clinical services you would like to provide to the ageing community? *

Is there someone responsible for reconciling bank statements? If yes insert name and title *

Is there someone responsible for reconciling EOB and income? If yes insert name and title *

Provide monthly expenses for advertising (printing, postage and other marketing services)? *

Provide monthly expenses for dues or memberships? *

Provide monthly expenses for drug costs? *

Provide monthly expenses for office supplies? *

Provide monthly expenses for CEs? *

Provide monthly expenses for donations or gifts? *

Provide monthly expenses for software? *

Provide monthly expenses for phone and internet ? *

Provide monthly expenses for clinical services? *

Provide monthly expenses for employee salaries? *

Provide monthly expenses for payroll taxes? *

Provide monthly expenses for lights and other utilities? *

Provide monthly expenses for rent? *

Provide monthly expenses for loans? *

Provide monthly expenses for liability business insurance? *

Provide monthly expenses for malpractice insurance? *

Provide monthly expenses for other ? *

list the item not listed

Provide monthly expenses for other ? *

list the item not listed

Describe your marketing plan to recruit new customers *

Do you have a customer appreciation program? *

yes or no

Does your staff generate leads for new customer referrals? *

yes or no

Do you provide news letters about your services monthly? *

Yes or No

Do you speak at service clubs or organizations ? *

Yes or No

Describe your ability to manage your time *

Describe your ability to promote your company *

Describe your motivation to succeed as a business owner. *

Describe your staff's ability to assist you succeed as a business owner. *

What self improvement efforts have you made? *

Describe your feelings about the present state of your practice *

Be very honest and detailed

What is your highest personal motivational factor

power money time with family peer impression

Describe what you would like to change about your practice *

Be very honest and detailed

List what your expectations are for us to assist you in improving your practice *

Be very honest and detailed

What do you feel are your greatest strengths as an entrepreneur ? *

Be very honest and detailed

What is your practice's greatest strengths ? *

Be very honest and detailed

List of Clinical Services provided. Choose all services Practice wants Consultants to Provide.

Vaccine Implementation CCM program Implementation Remote AWV services Develop & improve Quality Measures for MIPS/MACRA Diabetes Self-Management Program Implementation Insulin Pump Training Functional Medicine Service Implementation Other- Free 30min client consultation and discussion to establish service need.

Services

Clinical Services $ 2,100.00

Establish a new program or revise an already established program. Protocol development, policy manuals, and billing strategies are included. Create, review, or develop clinical related protocols, policies and or manuals. Clinical service fee applies per program. Each program estimated time of completion may vary depending on current status of practice and which service is being implemented. See list of clinical services provided. Initial Fee includes 10 hours of consultant time. If greater than 10 hours are necessary to complete program implementation, an hourly fee of $95/hr will apply. An invoice for additional hours will be provided to the client. Invoice is due 30 days from receipt.

Quantity

Operations, Workflow, and Process Improvement Assessment $ 1,850.00

Our approach to incorporate innovative methods to build your business. Consultant will provide an assessment of current work flow to reveal business losses and areas where practice can improve patient care, & patient satisfaction. We will create an action plan for improvement strategies that will benefit and build business. Initial fee includes 10 hours of consultant time. If greater than 10 hours are needed to complete the assessment, an hourly fee of $95/hr will apply. An invoice for additional hours will be provided to the client. Invoices are due 30 days from receipt.

Monthly Business Coaching $ 850.00

Our approach to business includes clinical methods to upsell patient services and incorporate innovative methods to build business with patients and providers. Client and Consultant have 30 minute biweekly calls to discuss strategies to achieve clinical goals.

Total $ 0.00

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New Client Assessment Form

OWNER PERSONAL DATA

COMPANY INFORMATION

Equipment and Software

Whole Saler and Supplier Details

Maintenance, Operations, and Clinical Services Review

Business Operations and Expenses

Customer Outreach and retention

Client Strengths and Weakness

Consultant Service Agreement

Payment Terms:

Term of Agreement:

AUTONOMY

Confidentiality: