Practice Questionnaire

In order to conduct a valuation of your practice, we will need some additional data points about your clinic legal entity and any related legal entities. We will review and prepare for a conversation about partnering with you shortly afterwards. Please include the following:

1) Tax returns for the last three years.

2) Profit and Loss (P&L) statements for the last three years for all entities with active cash flows.
Please highlight:

a. Monthly rent expense
b. Any outstanding loans, including PPP loans
c. Any non-business related revenues or expenses. This can include salaries paid to family members, personal vehicles, retirement contributions, etc.

3) A representative accounts receivable file or billing report from last year, including information on annual revenue by CPT code including allowed amount, paid amount, site of care, date of service, site of service (e.g. office, inpatient, ICU), rendering provider, and primary payor. We can help you locate this report in your EHR.

4) Information about your physical space including:

a. The addresses of any clinic or center you operate
b. # of exam rooms in each location
c. square footage per location
d. What services you perform per location, if service lines vary

5) Your CV, along with details on any medical malpractice lawsuits you’ve been involved in or reprimands by the state medical board, if any.

Please also include the following information about yourself and your employees:
- Employee Name
- Job Title
- All-in Compensation
- Hours Worked / Week

Employee Name
Job Title
All-in Compensation
Hours Worked /Week
As discussed, the purpose of this information is to allow Nimbus to construct a valuation of your practice and make an offer. Your responses to these questions are completely confidential. We look forward to our next conversation.

Thank you,

Clay Spence