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					                                                                                                                                                                         Ambulatory Anesthesia Service
                                                                                                                                                                                  Survey for Coverage
                                                                                                                                                                           Downloadable at

Contact Information:
Contact Name:                                                                                                              Return a completed survey to:
Center Name:                                                                                                                           Mail: 3079 Peachtree Ind. Blvd, Duluth, GA 30097
Mailing Address:                                                                                                                       E-mail:
Phone Number:                                                                                                                          Fax: 678-546-3606
Email Address:                                                                                                                         Attn: Partner Development Representative

Current Status:
Are you currenty contracted with an anesthesia group?                               Yes   No         Number of current anesthesiologists at facility on daily basis?                                           -
If yes; is the contract exclusive to the center?                                    Yes   No         Are the current anesthesiologists employed by facility?                                Yes         No

When are you targeting to execute a new agreement?                                                   Number of CRNAs at facility on daily basis?                                                               -
Do your anesthesiologists provide service to other facilities?                      Yes   No         Who employs CRNAs (ie. anesthesiologists, facility, contracted separate)?
Does your facility subsidize anesthesia?                                            Yes   No         Which staffing model do you desire: MD only, CRNA only or MD&CRNA
How much is the subsidy?                                                        $               -    What areas are you looking to improve (i.e., reduce subsidy, improve coverage, etc)?

Room Coverage
Total number of operating and procedure rooms?                                                  -
Number of rooms utilized on a daily basis requiring coverage?                                   -
Number of rooms staffed by anesthesia (7 a.m. - 3 p.m.)?                                        -
Number of rooms staffed by anesthesia (3 p.m. - 5 p.m.)?                                        -
Number of rooms staffed by anesthesia (5 p.m. - 7 p.m.)?                                        -
Is there a Saturday schedule?                                                       Yes   No

Number of locations for anesthesia on Saturday?                                                 -

Case Volumes (as opposed to Procedure Volume) by Type:                                                                             Anesthesia Case Volume by Payor:
What timeframe is represented below (i.e. annual, month, etc)?

                                                       Surgery Center                                                                                             Network Status            Surgery Center
                                                                                                                                                                Required of Anesthesia
                                                             Outpatient                                                                                                                           Outpatient
General                                                                     -                                                      Aetna                            In         Out                                 0%
Orthopedic                                                                  -                                                      BCBS PPO                         In         Out                                 0%
Urology                                                                     -                                                      BCBS other                       In         Out                                 0%
Ophthalmology                                                               -                                                      Cigna                            In         Out                                 0%
Cardiac- CABG                                                               -                                                      United Healthcare                In         Out                                 0%
Neurology                                                                   -                                                      Other commercial                 In         Out                                 0%
Vascular                                                                    -                                                      Medicaid, HMO Medicaid, etc.          N/A                                       0%
ENT                                                                         -                                                      Medicare, Pacificare, etc.            N/A                                       0%
Gastroenterology/Endoscopy                                                  -                                                      Self-pay                              N/A                                       0%
Gynecology                                                                  -                                                      Champus                               N/A                                       0%
OB - Epidurals                                                              -                                                      Workers' Comp                         N/A                                       0%
OB - C-Sections                                                             -                                                      Direct contracts                      N/A                                       0%
Podiatry                                                                    -                                                      Free clinic                           N/A                                       0%
Other:       Type?                                                          -                                                      Other:      Type?                                                               0%
Cases NOT requiring anesthesia                                              -                                                      Total                                                                           0%
Total                                                                       -

Are local anesthesia cases included in above mix?                                   Yes   No

Are any non-anesthesia cases included in the above mix?                             Yes   No

Please provide on a separate page the top 20 surgical procedures by CPT and/or ICD 9 codes including case volumes.                                                                          Yes         No

Additional Detailed Information                                                                                                    Additional Detailed Information
WHEN POSSIBLE: To help us provide the most accurate                                                                                How did you hear
revenue forecast form the start; please provide electronic
                                                                                                                                   about AHP?
copies of historic schedules, procedure types by code and
detailed payor mix breakdowns. Of course, we can provide
initial estimates without this detail, but prefer to set proper
expectations from the initial forecast.                                                                                            Additional Information Available:
                                                                                                                                   Video: Anesthesia Designed for Ambulatory Surgery Centers
Please check one:         Additilonal data is available at a later date.                                                           Video: Propofol Sedation for Endoscopy Suites
                          This represents all the data we have available.                                                          Article: Outsourcing Anesthesia - AHP's Invited Guest Approach
                          We have included additional data with this survey.                                                       Article: Anesthesia in an Ambulatory World - SurgiStrategies

           Confidential                                                                   Anesthesia Healthcare Partners, Inc                                                                Page 1 of 1

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