AHCA PPEC Financial Affidavit Questionnaire

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

   Legal Name of Entity
   
   Address
   

      

   Phone
   
   Fax
   
   Email Address
   

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

   Year 1
   
   Year 2
   

3. Average number of units (hours) per patient:

4. Average revenue or charge rate per unit (hourly or daily charge) of service:

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

6. What services will be provided to the patients?

7. What clinical services will be provided by employees?

8. What clinical services will be provided by independent contractors?

9. 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)
   

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

11. How much will you pay the Medical Director?

12. What other administrative positions will you need, and how much will you pay them? (ie: secretary, front desk, scheduling)

13. How much will you pay for administrative and overhead expenses each month? Please list the expenses separately below:

    Rent
    
    Office supplies
    
    Phones
    
    Insurances
    
    Professional Feess
    
    Utilities
    
    Repairs and Maintenance
    
    Other (please specify)
    

14. What payer sources will you use and what percentage of the business will they be? (ie: 50% Private Pay, 50% Medicaid, etc.)

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