Dermatology Questionnaire

To determine if your group practice qualifies for the clinical and financial benefits of the In-Path^SM program, please complete our confidential online form below or click to download a PDF version In-Path^SM Pre-Qualification Questionnaire.

If you have any questions about the information requested in the In-Path^SM Pre-Qualification Questionnaire, or if you would like to schedule a private meeting, please contact us or call 1.877.446.7284.

Name:

Address:

City, State, Zip:

Phone:

Fax:

(including area code)

1. Name of group practice:

2. Are you a "group practice" as that term is defined by the Stark Law?

Yes No

3. Number of physicians in group:

4. Skin Biopsy: (Please provide the average annual biopsy pathology statistics for your practice, including the percentage of pathology specimens that your practice can direct to the pathology lab of its choice):

	# of Cases	Avg # of Biopsies / Case	Avg # of Specimen Containers / Case	% Directed
Ambulatory Surgery Center:
Office:

5. If you place more than one biopsy in a specimen container, please explain the protocol.

6. Your group may be limited or restricted in its ability to direct pathology specimens to the laboratory of your choice based on the patient's insurance carrier. Please provide the following patient allocations to assist us in our analysis:

	% Medicare
	% Medicaid
	% Managed Care (PPO)
	% Managed Care (HMO)
	% Commercial
	% Self Pay
	% Other
100%	Total Patients

7. Is your group anticipating a volume increase (or decrease) of 10% or greater within the next twelve month period?

Increase: Yes No

If yes, please explain:

Decrease: Yes No

If yes, please explain:

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Dermatology Questionnaire