Allergy Practice Analysis
Clinic Information
Legal Name of Practice (Include Suffix)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Fax Number
Website
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Hours of Operation
Practice days and hours
Rows
AM - Open
Lunch
PM - Close
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Administrator
Contact Info
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
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Office Manager
Contact Info
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
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Operations
Type of Practice (ENT, Internal Med, Pain, etc.)
Number of years in business
Number of years at location
Total number of patients seen weekly
Number of NEW patients seen weekly
Other practice location(s)
Does the practice plan to have any material changes within the next 60 months?
Yes
No
Does the practice now provide or has the practice ever provided allergy testing or immunotherapy?
Yes
No
Do you use an outside billing company?
Yes
No
Do you receive payments electronically?
Yes
No
Is the practice involved in any capitation contracts
Yes
No
If yes, please explain
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Clinic/Office/Exam Room Info
Approximate size of building/office space?
Square Feet
Total number of treatment/procedure rooms?
Does the Practice have a room that can fully (100%) be dedicated to the onsite allergy center?
Yes
No
If yes, how many square feet would be available?
Square Feet
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Insurance
What is the average term on your insurance contracts?
Total number of years
Networks
In Network
Out of Network
Percentage of patients with commercial insurance?
%
Percentage of patients with United Health Care insurance?
%
Following the patient encounter, how long until the electronic HCFA is submitted?
Rows
Number
Days
Weeks
Contracted rates for the following CPT codes
Rows
95004
95024
95165
94010
95044
BCBS
UHC
Humana
Aetna
Cigna
Medicaid
Medicare
Other:
If other, name of company?
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Providers Info
How many providers are currently at this location
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Physicians Info
Physician 1
First Name
Last Name
Mobile Phone Number
-
Area Code
Phone Number
Email
example@example.com
Physician 2
First Name
Last Name
Mobile Phone Number
Email
example@example.com
Type a question
Physician 3
First Name
Last Name
Mobile Phone Number
Email
example@example.com
Physician 4
First Name
Last Name
Mobile Phone Number
Email
example@example.com
Physician 5
First Name
Last Name
Mobile Phone Number
-
Area Code
Phone Number
Email
example@example.com
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