ChiroEquity Solutions G.M. Kingsbury, D.C. 48 Murray Hill Sq. Phone: (908)419-7510 New Providence, NJ 07974 Fax: (908)790-0984 Practice Profile A. Clinic Name: Shrewsbury Chiropractic Center, LLC B. Owners Name: Dr. Daniel Kutschman C. Clinic Street Address: 200 Hwite Rd., Suite 111 D. City, State, Zip: Little Silver, NJ 07739 E. Telephone: 732-530-4088 F. Years in Practice 25+ years G. DC S 1 MD S DO S PT S LMT S CA S 3_ H. Sole Prop LLC Part ship Corp C Corp PA I. Straight: Mixer J. Adjusting Technique (s) : Diversified, Actiivator, CBP, AK, Cox, Drop Primary: Diversified Secondary: Blend Other: K. How many patients files on hand? Several hundred L. Last year average-visits per patient. (Patient Retention) 36.30 M. Last years average charges per visit: $ 37.90 N. Total patient visits last year 1924 O. Office Statistics: (1) Usable square feet 1017 Owned X Leased Lease Amount $ (2) Patient parking spaces: unlimited (3) Free standing or multi-tenant: multi-tenant (4) Location: Little Silver Commons (5) Signage: Professional Office Condo Lobby Directory) (6) Additional DC capability: Yes P. Does Doctor own other clinics? No Number Q. Attach complete listing of fees for services provided. Available upon Request R. Clinic Hours M: 3:30-7:00 W: 8:30am-7:00pm and 3:30pm-7:00pm F: 8:30am-1:00pm and Every other Saturday 8:30am-11:00am
Rate your office Circle One Poor Excellent How well equipped is your clinic? 1 2 3 4x 5 Do you have enough space in your clinic? 1 2 3 4 5x Is your clinic easy to find? 1 2 3 4 5x Is your clinic on a busy street? 1 2 3x 4 5 Is your clinic well marked? 1 2 3 4 5x Is your clinic visible? 1 2 3 4x 5 Is your clinic accessible? 1 2 3 4 5x Does your clinic have adequate parking? 1 2 3 4 5x staff NOTE: If your spouse, relatives, or any special people work for you, please indicate their relationship when filling out the information below. Name: Jason Drews_ Length of Employment: 2.5years Salary Hourly $10,00_ Contract Labor General Duties Office Manager Hours Required to Work M W Th F 7 am to 1 pm Doctors Personal Evaluation Poor 1 2 3 4 5 6 7 8 9 10 Excellent Name Phylis Richards Length of Employment currently training Salary Hourly $10/Hour Contract Labor General Duties Receptionist Hours Required to Work Doctors Personal Evaluation extremely responsible and compassionate
Staff - continued NOTE: If your spouse, relatives, or any special people work for you, please indicate their relationship when filling out the information below. Name Length of Employment Salary Hourly Contract Labor General Duties Hours Required to Work Doctors Personal Evaluation Poor 1 2 3 4 5 6 7 8 9 10 Excellent Name Length of Employment Salary Hourly Contract Labor General Duties Hours Required to Work Doctors Personal Evaluation Poor 1 2 3 4 5 6 7 8 9 10 Excellent Name Length of Employment Salary Hourly Contract Labor General Duties Hours Required to Work Doctors Personal Evaluation Poor 1 2 3 4 5 6 7 8 9 10 Excellent
A. Gross Billing:.........2006 245,042 2005 239,220 2004 248,662 B. Gross Receipts:....... 2006 192,670 2005 198,525 2004 194,782 C. Overhead:........... 2006 99,521 2005 95,352 2004 87,608 D. January-Present for 2007 all above categories: Included as attachment NOTE: Exclude all depreciation charges and all expenditures for doctor s salary, bonus and fringe benefits (i.e. automobile, dues, and memberships, lifehealth-disability insurance, retirement plan contributions, etc.) D. HMO/PPO Groups currently working with: Blue Cross/Blue Shield, Tufts, Harvard Pilgrim E. Approximate dollar amount collected from the HMO/PPO groups last year: $50,659 F. Attorneys: G. Legal Networkers: H. Specialized Referrals from other sources: I. ACCOUNTS RECEIVABLE: 1. Present Balance: $ 15,883 2. Aging Schedule Current $ 8,725 91 120 $ 5,007 31-60 $ 1,915 121-120 $ 61-90 $ 235 181 Plus $ 3. Receivable Profile: Patients Direct Pay... $ 1,391 Private Insurance... $ Workman s Comp... $ 2,988 HMO/PPO (by carrier)... $ 11,112 Personal Injury... $ 1,902 Medicare/Medicaid... $ 3,322 Other... $ J. CLINIC NET ASSETS:... $ Included as 2 attachments: Condominium Asset Schedule & CCWC Asset Schedule NOTE: Include only those assets owned or leased by the clinic. Land at cost, building net of accumulated depreciation, and furniture, fixtures, equipment, leasehold improvement and capitalized leases net of accumulated depreciation. Exclude cash, marketable securities (if any) and accounts receivable.
Please list your practice statistics for the last 12 months Month/Year Collections Services New Patients Total Visits May/2006 16,481 20,288 11 274 June/2006 17,453 22,978 13 304 July/2006 16,368 22,684 21 301 Aug/2006 13,546 14,766 8 192 Sept/2006 19,294 21,485 14 276 Oct/2006 16,498 22,150 6 286 Nov/2006 14,102 20,425 14 266 Dec/2006 12,574 18,599 9 239 Jan/2007 16,098 21,398 9 278 Feb/2007 14,943 13,880 5 183 Mar/2007 16,924 19,974 14 245 Apr/2007 11,967 13,574 2 173 12 Month Totals 186,248 232,201 126 3,017 (ChiroEquity Solutions use only) CA PVA OVA NPA CR HMO/PPO COLLECTIONS REPORT
If you are an HMO/PPO provider, please complete the following information. If you do not have exact figures, please estimate, but be as accurate as possible. This form will be presented to qualified prospective purchasers and their advisors. AMOUNTED COLLECTED NAME OF PROVIDER YEAR Blue Cross Blue Shield 41,633 Harvard Pilgrim 5,629 Tufts Health Plan 3,397 OTHER: K. Assumable Liabilities: $ 0 NOTE: Include only those liabilities selling doctor expects buying party to assume. L. Lease Obligations: 1. List all equipment, automobiles, data processing, office space, and any other assets leased by the practice/clinic. MONTHLY ITEM LEASE PAYMENT LEASE TERM
none M. EQUIPMENT A. Rate your present equipment: Overall, the office is in excellent condition. B. List each major piece of equipment you use in your practice (i.e. adjusting tables, ultra sound, x-ray, etc.) Qty Year or Age DESCRIPTION (Include Make, Model & Mfgr.) Serial Number For Items over $500 Own Lease Original Value 1 20 Zenith Cox Distraction Table (Verti-Lift) Very Good X 5,000 1 18 Zenith Cox Distraction Table (Verti-Lift) Very Good X 5,000 1 20 Zenith Hi-Lo Table (Verti-Lift) Excellent/Mint X 6,000 1 13 Mettler Interferential / Ultrasound Excellent X 3,244 1 6 Mettler Interferential / Ultrasound Excellent X 2,700 1 3 Computer - Dell Dimension 4600 Series Excellent X 814 1 6 mo Computer - Toshiba Satellite A105 S4384 Excellent X 875 Software - Eclipse Practice Management Software - Write Pad Medical Record System
PRACTICE DOCTOR N. DOCTORS BACKGROUND 1. Chiropractic College/Year National College of Chiropractic / 1986 2. Post Chiropractic College educations Doctor observation Practice What do you see as the strongest two areas in your practice? A. Uncompromising personal attention to patient care from entire staff. This has developed a large percentage of long term (+15 year) patient relationships. B. Atmosphere. The feeling in our office has created an oasis for the community providing a safe place to express and share from the heart. A & B result in a practice based strongly upon patient referrals. I have never advertised to obtain business. What do you see as the weakest two areas in your practice? A. Availability. Patient care is offered 3 ½ days per week. Also, I do not obtain coverage during vacations. Instead, we refer to local colleagues. B. Limited participation in HMOs and PPOs.
Personal What do you see as your two strongest attributes as they relate to your practice? A. Deeply compassionate. B. I utilize an integrative approach and incorporate diagnostic tools and treatment options from both the conservative and allopathic paradigms. The result is a practice which not only manages musculoskeletal injury but one that coordinates care for conditions ranging from emotional disease to organic pathology. Consequently, I receive many referrals from medical physicians. What do you see as your two weakest attributes as they relate to your practice? A. As mentioned above, I have chosen to limit my availability for patient care to 3 ½ days per week. B. Patient notes. I use Write Pad and feel that my patient records are currently above average and need improvement to be considered excellent. Miscellaneous My office is used as a Free Care Medical Clinic one night per week serving the uninsured and underinsured.