AHCA Home Health Financial Affidavit Questionnaire

1. Legal name of entity, address, county, phone, fax number, and email address:

   Legal Name of Entity
   
   Address
   

      

   County
   
   Phone
   
   Fax
   
   Email Address
   

2. Projected number of patients anticipated in year 1 and year 2:

   Year 1
   
   Year 2
   

3. If a CHANGE OF OWNERSHIP (CHOW), please provide most recent year-end financial statement. If it is a Medicare certified agency, please provide the most recently filed Medicare Cost Report. Please email michelle@egortcpa.com and CC marc@egortcpa.com.

    

4. If a CHANGE OF OWNERSHIP (CHOW), please provide most recent year-end visit breakdown by discipline and payer source.

5. If a CHOW, please indicate the purchase price and the terms. Please provide an amortization schedule if payments are made over time.

6. Average number of visits (hours) per patient by service:

7. Average revenue or charge rate per patient.If treating Medicare patients, please provide the average HHRG rate per episode. As the PDGM model for Medicare reimbursement is in effect, please indicate anticipated collection time for of the Medicare billings.

8. Do you anticipate any revenue reductions? (ie: bad debt expense, contractual allowances, charity work, etc.)

9. What services will be provided by direct employees (ie: RN, HHA, MSS, Homemaker, Companion, etc.) as indicated on the APPLICATION? What are their pay rates?

10. What services will be provided by independent contractors (ie: PT, OT, and ST) as indicated on the APPLICATION? How much will you pay them per service?

11. What startup costs will you incur? Please indicate the projected amounts:

    License Fees
    
    Inventory
    
    Equipment
    
    Insurance
    
    Advertising
    
    Consulting Fees
    
    Rent
    
    Accreditation Fees
    
    Utility Deposits
    
    Other (please specify)
    

12. Available cash (start-up capital) and its source:

13. Please list the salaries for the following (if applicable). Please confirm the requirements and position on the application as well.

    Administrator
    
    Director of Nursing
    
    Alternate Administrator
    
    Alternate DON
    
    CFO
    

14. What other administrative positions will you need, and how much will you pay them? (ie: scheduler, front desk, secretary, billing, etc.)

15. How much will you pay for overhead expenses each month? Please list each item separately and include other expenses not listed below:

    Rent
    
    Supplies
    
    Phone
    
    Insurance
    
    Professional Fees
    
    Franchise Fees (if applicable)
    
    Repairs and Maintenance
    
    Education
    
    Utilities
    
    Other (please specify)
    

16. What payer sources will you use and what percentage of the business will they be? (ie: 90% Insurance, 10% Private pay)

This will help us get the process started. If you have any questions, please call me at (754) 301-2183.