AHCA DME 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. Estimate of start-up costs by type:

   Consulting and Legal
   

   Inventory
   

   License Fees
   

   Accreditation Fees
   

   Equipment
   

   Other (please specify)
   

3. Administrative and direct employees: Position (part time and full-time) and annual salaries:

   Administrator/General Manager
   

   Delivery
   

   Intake
   

   Repair & Maintenance
   

   Personnel/Complaint Records
   

   Financial Officer
   

   Admissions Director
   

   Bookkeeper
   

   Secretary
   

4. Types of DME sold and average charge per unit (or capitation rate per unit if applicable):

   Respiratory Modalities
   

   Ambulation Aids
   

   Mobility Aids
   

5. How many units of each individual item listed above in #4 do you estimate will be sold in year 1 and year 2?

   Year 1
   
   Year 2
   

6. Types of DME RENTED and average charge per unit:

   Respiratory Modalities
   

   Ambulation Aids
   

   Mobility Aids
   

7. Will there be any revenue reductions? (ie: contractual allowances, bad debts, etc.). If so please estimate the reductions.

8. What is the cost per unit of each item of HME that you sell?

9. Breakdown of other overhead expenses:

   Supplies
   

   Rent
   

   Phone
   

   Insurance
   

   Professional Fees
   

   Franchise Fees
   

   Repairs and Maintenance
   

   Education
   

   Utilities
   

   Other (please specify)
   

10. How long will you expect to collect the accounts receivables? (ie: days outstanding)

11. How often will you pay payroll? (ie: semimonthly, weekly, bi-monthly, etc.)

12. When will rent be paid (end of month, beginning of month)?

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

14. What payer sources will you use and what percentage of the business will they be? (ie:, 20% Insurance, 20% Private Pay, 10% Medicare, 50% Capitation, etc.)

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