Questionnaire

Questionnaire Form

Please answer all questions below
Minimum of 6 months to 1 year of aggregated data for current year.

"*" indicates required fields

Name*

First Last

Email*

Phone

Company

Average 1-30 HHRG Day Payment*

Average 31-60 HHRG Day Payment*

Average Case Mix Index*

Total Average of Referrals (ALL Payors) per Month*

Average Monthly % of Episodic Referrals*

Average Nursing visits per 30-day billing cycle*

Average episodic LUPA rate (average # per month)*

Average 1-30 Day # of episodic LUPAs*

Average 31-60 Day # of episodic LUPAs*