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GENERAL INFORMATION

Facility Name *

Facility Address *

Contact Name *

Contact Title

Contact Phone Number *

Contact Email Address *

Number of Licensed Beds

Total Annual Admissions

Annual Non-Acute or Specialty Admissions

Specialty Type

Total Annual Adjusted Patient Days

Annual Non-Acute or Specialty Adjusted Patient Days

Case Mix Index (Optional)

Number of Surgical Procedures (Optional)

Please specify if the value is Per Month or Per Year.

Total Revenue

Total Operating Expenses

Total Supply Expenses

Surgical Supply Percentage

Please specify the percentage of surgical supply expenses out of the total supply expenses above.

Medical Supply Percentage

Please specify the percentage of medical supply expenses out of the total supply expenses above.

Ancillary Supply Percentage

Please specify the percentage of ancillary supply expenses out of the total supply expenses above.

Other Supply Percentage

Please specify the percentage of other supply expenses out of the total supply expenses above.

Total Purchased Services Expenses

Surgical Service Percentage

Please specify the percentage of surgical service expenses out of the total purchased service expenses above.

Medical Service Percentage

Please specify the percentage of medical service expenses out of the total purchased service expenses above.

Ancillary Service Percentage

Please specify the percentage of ancillary service expenses out of the total purchased service expenses above.

Other Service Percentage

Please specify the percentage of other service expenses out of the total purchased service expenses above.

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