ASC Valuation Data Request Addendum

Professional Management & Marketing 3468 Piner Rd•Santa Rosa•CA•95401-3954 Ph 707-546-4433 • Fax 707-546-4437 Email: [email protected]

(to be completed in addition to applicable parts of the basic Questionnaire) Response in Microsoft Word attachment is preferred to handwritten answers. Please mark answers as “N/A” rather than leaving blanks.

Facility licensure, accreditations & credentials, expiration/renewal dates, and any denials, reprimands, probations, suspensions, or revocations

Is the facility freestanding, or office-adjacent/practice affiliated? Provide copy of lease

Is the facility within 35 miles of an acquiring hospital

Names & specialties of physician owners and years of participation

List any hospital, co-management company, IPA, large medical-group or other ownership or alignment relationships or current alignment negotiations. Provide copies of contracts.

Copy of the shareholder agreement(s)

Copy of any current business plan or strategic plan

Names of non-invested participating physicians

Facility case mix and volume

Number of ORs & procedure rooms, and percent of utilization of operational capacity

Is general anesthesia provided

Case mix and volume and block-time by physician

Primary hospital affiliation(s) or preference of owners & referrers (the physician-practice referral-base of participants, particularly PCPs)

Competition and their ownership and/or joint ventures and/or management company

Other hospitals in market by name and chain-affiliation if any

Local-market physician acquisition & employment activity (Foundations, IPAs, insurance-company, hospital-managed groups, Accountable Care Organizations, integrated-models, etc), particularly as it related to primary care physician referrers to the ASC participants, and competition to those participants. Recent local-market ASC sales, and type of acquiror (physicians, management companies, other ASCs, hospitals, ACOs, etc)

Describe any recent retirement or exit of participants, and if to a competitor

If physician-user satisfaction studies have been performed, provide report or summary

If patient and/or referrer satisfaction studies have been performed, provide report or summary

If a management-consultant report on practice operations has been performed, provide a copy

If a benchmarking, HOPD, supply-costs, or other report is available, provide a copy

Identify any preferential, individually-negotiated reimbursement agreements with payors. Provide copies of contracts

Identify any significant outsourcing contracts and provide copies (ie anesthesiology, billing, compliance, payroll, EMR/IT, etc).

Identify any Quality Reporting (“G-code”) non-compliance.

If EMR is used, is it the same product –or is it HL7-compliant– with that of participating physicians, or with other local entities like IPAs or hospitals?

Describe patient wait-times for appointments, and recent trends

Describe any out-of-network reimbursement ratio, strategy, or trends

Describe any high-profile, high-marketing, dominant, or noteworthy participants

Describe any incidents of negative publicity, scandals or media reporting regarding facility or participants

Describe any other positive or negative issues that you think might affect value