Medical Practice Questionnaire

e3Business, LLC

Financial Questionnaire
1. Your Name

First NameLast Name
2. Practice Name
Operating Name of the Practice
3. Email
example@example.com
4. What products do you offer?
5. What provider services do you offer?
6. What ancillary services do you offer?

7. How are point-of-service collections addressed?
8. What cash pay or patient agreements are used?
9. How are billing and collections addressed?

10. What insurances does the practice accept?
11. What is the average office visit payment?
12. What are the average monthly collections (or targeted collections)?

13. What vendors are used for supplies?
14. What vendors are used for services?
15. What vendors are used for insurance, (malpractice, business liability, etc.)?

16. How many people are employed by the practice?
17. How many independent contractors are used by the practice?
18. How is payroll/tax payment handled?

19. What financial relationships does the practice have (banks, financing, etc.)?
For the last question, it might be helpful to look at the e3Business Medical Practice Systems graphic HERE.
20. Is there anything else related to income/expense not already identified?
You will receive a PDF of your completed form at the email provided above.

You will need to use password Client#1 to access this file.
Should be Empty: