Title:
Name: (*)
Specialty:	Anesthesiology Physical Medicine & Rehabilitation Physical Therapy Behavioral Medicine Other
Address 1: (*)
Address 2:
City: (*)
State:	ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA 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 OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING OTHER   Zip Code:(*)
Phone: (*)	Ext:
Fax:
Best time to call:	: AM PM
E-mail: (*)
1.   Average monthly expenses per physician, excluding physician compensation  $ 2.   Monthly rent  $ 3.   Monthly leases  $ 4.   Monthly staffing cost           a.   RN's    $           b.   LPN's  $           c.   MA's   $           d.   Tech   $           e.   Admin $ 5.   Monthly supply cost  $ 6.   Monthly resource cost  $ (billing, IT, public relations, consultants, accounting, etc.) 7.   Monthly utilities, phone & taxes  $ 8.   Monthly storage fees  $ 9.   Monthly transcription fees  $ 10.   Miscellaneous costs  $ (landscaping, housekeeping, disposal, mileage, etc.) 11.   Monthly staff education cost  $
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