Confidential Practice Questionnaire2 Form

Practice Management Associates Secure form

Confidential Practice Questionnaire

Drs Name:

DDS

DMD

Spouse:

Work Address:

Home Address:

Business Phone:

Home Phone:

Cell Phone:

Home Fax:

Preferred Contact:

Cell

Home

Business

Website:

Confidential to Staff?:

How did you hear about us? (colleague, website, seminar, Google):

Reason for Sale/Transition:

Dental School Attended:

Year Graduated:

Under Graduate College:

Advanced CE - Specialty training:

Left

or

Right Handed

Operatories Interchangeable:

Yes

No

Amount owed on Practice or Equipment:

How long have you owned your practice?

How long has the practice been located at this location?

Do you have Equipment that is Leased?:

Building Information: Sq. ft

Total Number of Rooms:

Total Hygiene Rooms:

Is Building owned or leased?:

Monthly Rent: $

Leasing end date & extentions:

If you own, do you wish to Sell or Lease or Either way:

Other Notable Equipment:

Is any treatment referred out?:

Adjunctive Services Provided:

IV / Conscious Sedation

Ortho

TMJ

Sleep Appliances

Other Adjunctive Services Provided:

Hospital Dentistry?:

Dental Practice Management Software:

Version:

Total number of new patients YTD Last year total

Breakdown by percentage of referral sources:

Patient referral

%

Walk ins

%

Advertising

%

PPO/insurance

%

Website/SEO

%

Other

%

If other please explain

Doctor and Staff Schedule (days of week and hours):

List any participating PPO or reduced fee programs:

Do you accept Medicaid or social services patients?:

The above and below information accurately describes my practice to the best of my knowledge.

Dr

Date

Practice Management Associates

- Current Staff -

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

Name:

Title/Position:

Years with Practice:

Hours per week:

Wage:

Benefits:

How do you track employee hours? Employee benefits

Who handles payroll?

Who handles accounts payable?

Who handles monthly/quarterly taxes?

Family members employed by Practice? If so, monthly or yearly earnings:

Will they need to be replaced when you sell?

Please describe number of holidays, vacation days, sick days, you provide to your employees:

Do you give your staff pay increases annually, on their anniversary date or by merit?

Do you offer Medical Insurance?

Yes

No

Do you offer Dental benefits?

Yes

No

If yes to either of the above questions - please describe the type of benefits:

Are you or your family members covered under medical benefits that are paid for through the practice?

If so, what is the monthly cost for your benefits?:

Do you offer a Simple IRA or 401K?:

If so, please describe how benefits are rendered:

If you are your family members are included in the 401K overall contribution, what is the total amount deposited on your and their behalf for the last two years tax returns?

2017:

2018:

What are your practice financial arrangements?:

Internal Marketing: (referral programs, etc)

External Marketing: (Website, SEO, Newsletters, etc.)

Practice Management Associates

Requested Practice Data / Reports

Last two years business tax returns that are currently available (2017, 2018, 2019) 1120, 1120S or Schedule C with supporting statements
2019 Profit and Loss Statement and 2020 January through current month end
2019 Production/Collection Report totals
2020 2020 Production/Collection Report totals (January through current month end)
2019 Collection breakdown of private and insurance payments (if available)
2020 Collection breakdown of private and insurance payments (if available)
2019 Production by procedure code report and 2020 January through last month end
Production by provider report for 2019 and January through last month end for 2020
Current fee schedule for Fee for Service patients, and any PPO
2019 Insurance provider report (if available)
Current Accounts Receivable Aging Summary (Last page only showing 30, 60, 90+ days outstanding balances owed)
Copy of original office lease and current extension (if applicable)

Please email sensitive information using our encrypted email link on our email or website or send using your encrypted program if you have one.
If you prefer to mail with tracking, please mail to us at:

Practice Management Associates, LLC
31811 Pacific Hwy. S. B-191
Federal Way, WA 98003

If you have any questions, please call us at 888-762-4048

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