Practice Assessment Questionnaire

1. Copy of C.V. for each provider with Month/Year for education & work history

2. Copy of each providers:

3. Numbers for each provider

5. New Corporation Information

B. Copy Bank Letter noting name of account, tax ID, bank account number and bank routing number, signed by a bank representative (2 original letters)

6. List of hospitals, phone, and Addresses where each provider has privileges:

7. Previous information – used for filings before new corporation

13. CLIA Information:

14. List of Managed Care Plans each provider participates in as well as products they participate in, plans web portal User Name and Password for each plan, and reimbursement and provider numbers for each.

15. List of top 30 most common CPT codes for the practice

List of Leverage Points that make doctor unique and can create leverage with managed care plans to use for contract negotiations.

NOTE: Make additional copies for each provider as needed.