AHCA Registry 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. Average number of units (hours) per discipline (ie: RN, LPN, CNA, HHA, or Homemaker):

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

4. Average revenue or charge rate per discipline:

5. How much will you pay per unit of service for each discipline:

6. What startup costs will you incur? Please indicate the projected amounts:

   License Fees
   
   Inventory
   
   Equipment
   
   Insurance
   
   Advertising
   
   Consulting Fees
   
   Rent
   
   Accreditation Fees
   
   Utility Deposits
   
   Other (please specify)
   

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

8. How much will you pay the Administrator, and other office administrative positions?

9. How much will you pay each month for administrative and overhead expenses? For example:

   Rent
   
   Office Supplies
   
   Phones
   
   Insurances
   
   Professional Fees
   
   Utilities
   
   Repairs and Maintenance
   
   Other (please specify)
   

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

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