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 *

example@example.com

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? *

How Important Is Customer Service, Timeliness and Friendly Hospitality To You In Your NEXT Doctor? (1 Not Important At All; 3 Important; 5 Extremely Important/Must Have) *

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 Environment | 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

Yes, I concur that the information above is accurate and truthful. I agree to the terms above outlined in disclaimer and CMTs privacy policy.

Yes! No.

CONCIERGE MEDICINE TODAY: Physician Self-Test