AHCA Clinic Financial Affidavit Questionnaire

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

   Legal Name of Entity
   

   Address
   

      

   Phone
   

   Fax
   

   Email Address
   

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

   Year 1
   
   Year 2
   

3. For existing clinics or a Change of Ownership, please provide the most current financial statement including balance sheet and income statement (profit and loss). Please email michelle@egortcpa.com and CC marc@egortcpa.com.

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

5. If applicable: List of equipment products, cost and anticipated number of units sold and charge per item.

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

7. What services will be provided to the patients? (ie: primary care, chiropractic, dental, urgent care, diagnostics, follow up visits, etc.) These services should align with the services indicated on your application.

8. Average revenue or charge rate per unit of service. If the reimbursement rate is different from the charge rate, please indicate what that rate is. If a PMPM, please indicate as such.

9. What type of employees will you hire to provide the clinical services mentioned in #7, and how much will you pay each?

10. What type of independent contractors will you hire to provide the clinical services mentioned in #7, and how much will you pay each?

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

    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. How much will you pay the Medical Director? Are they full-time or part time?

14. What other administrative positions will you need, and how much will you pay them?

15. How much will you pay for the following overhead expenses PER MONTH?

    Rent
    

    Utilities
    

    Office Supplies
    

    Phones
    

    Insurance
    

    Professional Fees
    

    Repairs
    

    Education
    

    Advertising
    

    Other (please specify)
    

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

17. Days billing are outstanding in Accounts Receivable:

18. If a Change of Ownership, please indicate purchase price, terms, and amortization schedule if there is a payout over time.

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