CMT Self-Test

Please fill out this form below. Dependent upon your answers, you will be directed to a page that will provide you with a thorough analysis of why your practice may or may not be a good fit at this time to transition to a cash-based medical practice model. If your practice does meet the criteria to be successful in this type of practice, your practice will be selected to receive a complimentary consultation and someone will be in contact with you shortly regarding the positive results of your survey and explain what your future options are within your practice.

Your Name *

First Name Last Name

Phone Number *

- Area Code Phone Number

Your Medical Specialty *

Your E-mail Address *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How Many Years Have You Been In Practice? *

What is the size of your patient panel? *

(i.e. Include #er of patients seen only in the past 24 mos)

How many patients do you see per day? *

How many days per week do you treat patients? *

What Percentage of Your Practice Is 40+ Years or Older? *

What Percentage of Your Practice Is MEDICARE Eligible? *

WHY DO WE ASK 'ARE YOU MARRIED?'
This question is important because many physicians and their spouses work together in the same office. We've found time after time, that changing your business model requires the joint decision of both parties, whether they work together or not. If your spouse is not in agreement with the change, a transition to a concierge medical practice is not recommended.

Are You Married? *

Current Environement | Solo or Group Practice? *

I Work In A Group Practice. I'm The Only Physician In My Practice.

If GROUP OR You Indicated Other -- Please Describe How Many Doctors Work In The Practice?

How Would You Classify The Socio-Economic Profile of Your Patients? *

Working Class / Government Subsidized Lower Middle Class Middle Class / Affluent Upper Middle Class to Very Wealthy

Name of Current Billing Software (if applicable)

Name of Current EMR Software (if applicable)

How Long Have You Been Investigating These Cash-Based Practice Models? *

Under 3 Months 3-6 Months 6-12 Months 12+ Months

If You Were To Transition To A Cash-Based, Retainer-based or Direct-Pay Practice Model, When Would You Anticipate Moving Forward? *

Under 3 Months 3-6 Months 6-12 Months 12+ Months

What Motivates Your Interest In This Industry? (Check All That Apply) *

Become Less Reliant On Insurance/Managed Care Lifestyle/Work-Life Balance Financial Desire To Deliver Higher Quality Healthcare Desire To Work With Compliant Patients That Value Their Doctor

What Other Practice Models Are or Have You Considered? *

Cash Practice Work For Large Group Hospitalist Status Quo Retire Early

About Our Endorsed Industry Service Providers (I.e. EIPs) and Disclaimer

You may contact us directly at (770) 455-1650. Finding a reliable company or individual is sometimes difficult, particularly in this niche of healthcare. We have done our research and found these companies/individuals to be the best. What started as a service for one city has now grown to help numerous numbers of doctors across the nation. People love our simple process and the high-quality professionals we refer to. (Disclaimer)

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CONCIERGE MEDICINE TODAY: Physician Self-Test

Yes, The Information Above Is Accurate and Truthful.