Initial Questionnaire Form

STRATEGIC OUTPATIENT SOLUTIONS

Offering innovative tactics for challenging times

STRATEGIC OUTPATIENT SOLUTIONS
ASC Initial Questionnaire

For existing ASCs, the first step in the process is to complete our initial questionnaire. Within 24 hours of submission, SOS will be able to tell you whether we can help improve the profitability, efficiency, and patient satisfaction of your ASC.

If have any questions or need assistance completing the form, please call us (310) 984-6830.


Surgery Center Name:
Contact Name:
Contact Phone Number:
E-mail Address:
ASC Website:

1. Date ASC opened:
2. ASC is licensed by (Hold down "Ctrl" key to select multiple options):
3(a). # of Operating Rooms:
3(b). # Procedures Suites:
4(a). Licenses that the ASC holds:
4(b). If single specialty, indicate which specialty:
4(c). If multi-specialty, indicate which specialties:
5(a). Average monthly collections:
5(b). Average monthly operating income:
6. Average # cases ASC performs each month:
7. # Physicians who regularly operate at ASC:
8. # Physician investors who regularly operate at ASC:

9. Payor Mix by Volume:
9(a). Contracted Commercial %:
9(b). Non-Contracted Commercial (Out-of-Network) %:
9(c). Medicare %:
9(d). Medicaid %:
9(e). Workers' Comp:
9(f). Personal Injury:
9(g). Self-Pay %:
9(h)(1). Other (describe type):
9h(2). Other %:
10. Dominant insurance carrier in the market:
11. List payors ASC is contracted with:
12. Questions or Comments:

STRATEGIC OUTPATIENT SOLUTIONS
2934 1/2 Beverly Glen Circle, Suite 775
Los Angeles, CA 90077
(310) 984-6830
e-mail: info@outpatienttactics.com

Offering innovative tactics
for challenging times...