Before you begin completing this form, the person responsible for its completion must call our office (800.845.4766) for specific instructions. With an orthodontic practice? Please use our orthodontic form instead. Thank you!
Please supply the following information for the most recent six months. Do not include any orthodontic figures on this analysis. Zuelke & Associates will evaluate your information and contact you with an analysis of your practice.
Total Number of New Patient Exams: Each new patient, including emergencies, you have never seen before.
Gross Production: Total fees for treatment before subtracting any discounts, adjustments, write-offs, etc.
Adjustments: Any ledger entry that increases or decreases a patient or insurance balance (discounts, refunds, write-offs, etc.), other than fees and payments. Please be sure to note whether your Adjustments are a positive (+) or a negative (-) figure.
Gross Collections: Total money paid on patient accounts.
Number of Days Worked: Number of days each doctor was available to see patients.
Month
1. New
Exams
2. Gross Production
3. Any
Adjustments
4. Gross Collections
5. Days Worked
Accounts receivable aging at end of most recent month:
**Include 90 days and over & 120 days and over.
Please ensure that Aged 0-30, 31-60 and 61 and over (2+3+4) equals the total of all account balances (1).
