Covid-19 Practice Recovery Assistance

Please complete the following to assist us in determining the best course of action to discuss with you.

Name

First Name

Last Name

Phone

(###)

###

####

Your practice's name

Practice website

http://

Type of practice

If group practice, number of physicians

Number of mid-level providers

Number of clinical support staff

Number of administrative support staff

Accounts Receivable - Less than 30 days

Accounts Receivable - 31 to 60 days

Accounts Receivable - Over 60 days

Total monthly operating costs, excluding payroll

Total monthly physician & mid-level provider salaries

Total monthly support staff payroll

Total practice debt

Available cash on hand

Comments/Questions