Tuesday, April 24, 2018
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CSS Consulting Group
320 Arden Avenue, # 108
Glendale, CA 91203
818.957.2649 - PHONE
818.957.2790 - FAX
info@css-cg.com
General Information
Facility Name
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Facility Address
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Contact Name
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Contact Title
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Contact Telephone
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Contact Email
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Facility Information
Licensed Beds
Please enter the number of licensed beds
Total Admissions (Annual)
Please enter the number of annual total admissions
Non Acute or Specialty Admissions (Annual)
Please enter the number of non-acute or specialty admissions annually
Speciality Type
Please select any of the following specialty type(s)
Psych
LTC
Other
Total Adjusted Patient Days (Annual)
Please enter a number for Total Adjusted Patient Days (Annual)
Non Acute or Specialty Adj. Patient Days (Annual)
Please enter the number value for Non-Acute or Specialty Adj. Patient Days (Annual)
Case Mix Index (Optional)
Please enter the value for Case Mix Index
Surgical Procedures (Optional)
Please enter the number of Surgical Procedures. Please specify if the value is Per Month or Per Year.
Financial Information
Total Revenues
Please enter the value for Total Revenues
Total Operating Expenses
Please enter the Total Operating Expenses
Total Supply Expenses
Please enter the value for Total Supply Expenses
Surgical Supply Percentage
Please specify the Percentage of Surgical supplies from the Total Supply Expenses above.
Medical Supply Percentage
Please specify the Percentage of Medical supplies from the Total Supply Expenses above.
Ancillary Supply Percentage
Please specify the Percentage of Ancillary supplies from the Total Supply Expenses above.
Other Supply Percentage
Please specify the Percentage of Other supplies from the Total Supply Expenses above.
Total Purchased Services Expenses
Please enter the value for Total Purchased Services Expenses
Surgical Service Percentage
Please specify the Percentage of Surgical services purchased from the Total Purchased Service Expenses above.
Medical Service Percentage
Please specify the Percentage of Surgical services purchased from the Total Purchased Service Expenses above.
Ancillary Service Percentage
Please specify the Percentage of Ancillary services purchased from the Total Purchased Service Expenses above.
Other Service Percentage
Please specify the Percentage of Other services purchased from the Total Purchased Service Expenses above.
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