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Current Management Group (if any):

Group Provider Mix:
• Specialties: (the specialty and the total number)
• Family Practice: (number of physicians that are FP's)
• Internal Medicine: (number of physicians that are IM's)


Current Payer Mix (Enter Percentage, or Population Info):
• PPO:
• HMO:
• Medicare:
• Medicade:


Primary Payer Contacts:


Health Information Technology Adoption:
  • Currently up on Practice Management Solution:
      (vendor)
      (modules)
  • Currently up on Electronic Medical Record Solution:
      (vendor)
      (modules)
  • Purchased, But Not Yet Implimented:
      (vendor)
      (modules)
      (go-live date)
  • Plan to Purchase:
      (timeline)