POFOA | Proof of Financial Ability to Operate

First Name

Last name

Company name

Phone

Fixed Operating Costs

Office Sublease

Amount of lease or mortgage. [Please specify.]

General liability Insurance Payment amount

Mal Practice Insurance Payment amount

GL Payments Monthly or every 90 days?

Total Fixed Operating Costs

Clinical Staffing (Contracted)

Administrator per hour Rate [Minimum $20 Per Hour]

How many hours per week?

CFO per hour Rate [$20 Minimum]

How many hours per week

Per Hour or Annual [*Notes]

Medical staff per hour rate

How many hours per week?

Medical staff per hour rate

Monthly [Gross]

Please list additional staff + Position + rate

Total Additional Personnel

Medical Director [[$1500 minimum]

Total Clinic Personnel Per month

Operational Costs

Medical Supplies - If none, please please write it in the notes

Licensing and Permits

EMR / Practice Management Software / Billing

Office Suppplies

Phone | Internet | Electric Breakdown

Marketing / Business Development

Website | Marketing | Advertising

Miscellaneous / Contingency

Estimated buffer

Total

Total Estimated Monthly Operations/Budget

For the POFA requirement, showing approximately three months of operating reserves would be:

Estimated Monthly Payer Mix

Please estimate the percentage of patients you expect to see each month by payer type. The total must equal 100%.

Payer Type & Estimated % of Patients

Private Pay

Medicare

Medicaid

Commercial Insurance

HMO/PPO

Other

Total= 100%

Notes

If there is a form you do not have, pleae upload a blank PDF.