Name	(required)
Email address	(required)
MRI Facility Name
Phone Number	(required)

1.What do you expect to collect for a routine MRI exam (by payor class) and what do you anticipate the payor mix to be?

Commercial Insurance		% of my volume at	$ per exam;
Workers Compensation		% of my volume at	$ per exam;
No-Fault		% of my volume at	$ per exam;
Medicare		% of my volume at	$ per exam;
Managed Care		% of my volume at	$ per exam;
Other		% of my volume at	$ per exam;
Note: Please be sure you have accounted for 100% of your scan volume

2. What will the additional charge be for a procedure with Gadolinium?			$
3. How many days per week will the MRI facility be open for scanning?
4. How many hours per day will your staff be available for scanning?
5. How much of an allowance do you anticipate for bad debt?			%
6. What will you be paying per scan for radiology and transcription services?			$
7. How many MRI technicians will you employ Full Time?
8. How many MRI technicians will you employ Part Time?
9. What do you expect to be paying an MRI technician on an hourly basis?			$
10. Will you employ a receptionist?			yes no
11. What do you expect to be paying for a receptionist on an hourly basis?			$
12. Will the MRI facility have a dedicated manager?			yes no
13. What do you expect to be paying for a manager on an hourly basis?			$
14. How many square feet of office space have you leased?
15. What is your monthly payment including your share of taxes and common area maintenance charges?			$
16. What will the third-party billing service be charging you as a percentage of collections?			%
17. How many MRI scans do you expect to do on a daily basis?