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Request for Proposal
Tell us what you're looking for by filling our our RFP questionnaire below.
Step
1
of
10
10%
Hospital Name
Address
Street Address
Address Line 2
City
State / Province
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
CEO Name
COO Name
CFO Name
Contract Type Desired
Full-Time
Part-Time
Fee for Service
Hourly
Anticipated Start Date
MM slash DD slash YYYY
Emergency Department Payer Mix
(Please list as a percentage of ED patient volume)
Medicare
Medicaid
BlueCross/BlueShield
Self-pay
Worker's Comp
Collection
Avg. per patient charge
Commercial Insurance
Other
ED Levels of Care
(Physician component only- please list either a percentage or a total figure for the past year)
Level I
Level II
Level III
Level IV
Level V
Please list the major managed care carriers:
Is managed care participation required?
(Required)
Yes
No
Emergency Department Stats
Current Staffing Group
Current ED Billing Entity
Average Patient Volume
Special Conditions Affecting Volume
Hourly Coverage Desired per Day
Max Shift Length per Doctor
MD Pay/Hour
MD Pay/Month
Current Subsidy/Year
PA/NP Hour/Day
PA/NP Pay/Hour
Current Contract
Full-Time
Part-Time
Fee for Service
Hourly
Certifications
ACLS
ATLS
BLS
PALS
Documentation System
% of ped patients
Other certifications
Physician Requirements
Emergency Department Billing Patient Volume (Please do not include any "no charge" visits)
Number of billable patients in the previous year.
Month/Year-Month/Year
Billable patients previous year or fiscal year
Visits
Billable patients previous year or fiscal year
Patient admission rate from ED (%)
Month/Year
Billable patients current to date
Visits
Billable patients current to date
Are there any restrictive covenants or buy-out fees for your current group of physicians?
Yes
No
If yes, how much?
Prepared by:
Title
Phone
Email
Additional Comments?
Please attach last 3 months of physician coverage calendars and any additional supporting documents.
Drop files here or
Select files
Max. file size: 8 MB.
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