Physicians Seeking to Recruit/Sell a Practice Web Form

Please complete the information below, and click to submit. All information is confidentially stored, for internal use only. Physician/Practice Opportunity Profile

I am seeking to:
Recruit a physician for a practice Sell a practice
*Practice Name:
*Contact Name:
*Address
*Contact Number (xxx)xxx-xxxx:
*Contact E-mail:
Preferred contact method:		phone e-mail
Current Hospital Affiliations:
Specialty:
Reason for opportunity:
Practice Information
Number of physicians in practice:
Number of office staff (MA’s, PA’s, RN’s, CNA’s, etc):
In office ancillary services (x-ray, etc.):
Payor Mix:
% Medicare:     % BCBS:     % BCN:     % HAP:     % HMO: % of all other commercial ins:
% Collections:
Expenses:		(if selling practice)
Salary:		(if negotiable please state)
Incentives:
Office Hours:
Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:
Do the physicians round on their patients?		Yes No
Physician Criteria for Employment
Board Certified: Yes No Board Eligible: Yes No NA
Minimum expectations/comments:
Community Profile (if applicable, highlights of attractive venues, events, sports teams in area, etc)