Physician Recruitment Request

Practice Opportunity Profile - External

Physician Recruitment Request

Practice/Medical Group______

Address______

City ______State ______Zip Code______

Work Phone #______Fax #______

Home #______Pager #______

Specialty Needed ______Full time ______Part time______

Reason for opening______

______

Name of person requesting service (please print):______

Signature: ______

Title or Authority: ______

Recruitment Services Requested

Please Check Appropriate Box

Sourcing candidates and referring CVs to practice / Interview Guidelines
Pre-Screening interviews / Site Visit Support
Referencing checking / Financial Support
Background checking / Other
Supplemental referencing checking by telephone

Practice Profile

Type of practice (medical group, solo, partnership)______

Inpatient %:______;Outpatient %______

Weeknight call coverage:_____ - average # of calls taken:_____average # of hospital admits: ______

Weekend call coverage:______- average # of calls taken:_____average # of hospital admits: ______

Call coverage triage: Yes No

Number of hours worked per week: ______Hours the clinic is open______

Hospitals(s) used ______

Patient population (ages)______Ethnic mix______

Payor Mix______

Expected patient load ______Timeline to build practice______

Procedures needed______

______

Attraction to the position______

______

Attraction to the community______

______

Political environment______

Ideal candidate______

______

Compensation______

Employed physician/Shareholder______

Establishing Community Need

Total number of active patient charts______

Number of new patients per month______

Waiting time before patient can be seen by physician______

Volume of patients who would be referred to the new physician______

Timeframe for referral of patients to new physician: ____

Increased patient accessibility by _____%

Ability to transfer patients to other physicians in the community: Yes No

Any unique service offered______

______

MediCal patients _____%; Medicare patients _____%; Indigent care_____%

Volunteer work done for the community (emergency care, etc.)______

______

Financial Profile

Amount Requested______

Type of purchase (buy-out, partnership, other)______

Depreciation schedule (please attach to this form)______

Checking account statements for 12 months (please attach to this form)______

Three year profit-loss statement (please attach to this form)______

One year monthly accounts receivables aged balance by physician (please attach to this form)______

Schedules of charges, collections, and adjustments by physician for the prior year and year to date (please attach to this form)

Check registers for the prior year and year to date (please attach to this form)______

Business debt and leases (capital and operating)______

Gross physician-employee salaries paid by pay period______

Business paid health, dental, life, and disability premiums for all physicians______

List miscellaneous business receipts (medical directorships, stipends, loans, ER coverage, expert witness fees, etc.

Detail of capitation receipts for last 12 months (please attach to this form)______

Photocopy of five randomly selected days during the last two months of all appointment schedules with new patients indicated (please attach to this form)

Average number of capitated patients and non-capitated patients seen in the practice for the last 12 months_

Average number of new patients seen detailed by physician for the last 12 months______

Photocopies for the last two compilation reports prepared for the corporation (please attach to this form)