Request for Proposal – Correct Care, Inc.

Please complete the RFP Questionnaire below.

Hospital *

Date *

Address *

Phone *

City *

Fax

State *

Zip *

Contract Type Desired

Part Time

Full Time

Fee for Service

Hourly

Anticipated Start Date *

CEO *

COO

CFO

Emergency Department Payer Mix (Please list as a percentage of ED patient volume)

Medicare

Medicaid

BlueCross/Blue Shield

Self-pay

Other

Work. Comp

Collection

Avg. per patient charge

Commercial Insurance

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?

Yes

No

Emergency Department Stats

Current staffing group *

Current ED billing entity

Average patient volume *

Special conditions affecting vol.

Hourly coverage desired per day *

Max shift length per doc

MD pay/hour

MD pay/month

Current subsidy/year *

Current contract

Fee for Service

Hourly

Part Time

Full Time

PA/NP hour/day

PA/NP pay/hour

Documentation System

% of Ped patient’s

Certifications

ACLS

ATLS

BLS

PALS

Other Certifications

Physician requirements

Emergency Department Billing Patient Volume (Please do not include any “no charge” visits)

Number of billable patients previous year

Number of billable patients per date

Month/Year - Month/Year

Billable patients previous year or fiscal year

Visits

Billable patients previous year or fiscal year

Month/Year

Billable patients current to date

Visits

Billable patients current to date

Monthly patient admission rate from ED (percentage)

Are there any restrictive covenants or buy-out fees for your current group of physicians

Yes

No

If yes, amount?

Prepared by: *

Title:

Phone: *

Email: *

Additional Comments

Please attach last 3 months of physician coverage calendars and any additional supporting documents

Maximum file size: 33.55MB

PDF Only

Phone *