<p> Professional Management & Marketing 3468 Piner Rd•Santa Rosa•CA•95401-3954 Ph 707-546-4433 • Fax 707-546-4437 Email: [email protected]</p><p>ASC Valuation Data Request Addendum</p><p>(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.</p><p>Facility licensure, accreditations & credentials, expiration/renewal dates, and any denials, reprimands, probations, suspensions, or revocations</p><p>Is the facility freestanding, or office-adjacent/practice affiliated? Provide copy of lease</p><p>Is the facility within 35 miles of an acquiring hospital</p><p>Names & specialties of physician owners and years of participation</p><p>List any hospital, co-management company, IPA, large medical-group or other ownership or alignment relationships or current alignment negotiations. Provide copies of contracts.</p><p>Copy of the shareholder agreement(s)</p><p>Copy of any current business plan or strategic plan</p><p>Names of non-invested participating physicians</p><p>Facility case mix and volume</p><p>Number of ORs & procedure rooms, and percent of utilization of operational capacity</p><p>Is general anesthesia provided</p><p>Case mix and volume and block-time by physician</p><p>Primary hospital affiliation(s) or preference of owners & referrers (the physician-practice referral-base of participants, particularly PCPs)</p><p>Competition and their ownership and/or joint ventures and/or management company</p><p>Other hospitals in market by name and chain-affiliation if any</p><p>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)</p><p>Describe any recent retirement or exit of participants, and if to a competitor</p><p>If physician-user satisfaction studies have been performed, provide report or summary</p><p>If patient and/or referrer satisfaction studies have been performed, provide report or summary</p><p>If a management-consultant report on practice operations has been performed, provide a copy</p><p>If a benchmarking, HOPD, supply-costs, or other report is available, provide a copy</p><p>Identify any preferential, individually-negotiated reimbursement agreements with payors. Provide copies of contracts</p><p>Identify any significant outsourcing contracts and provide copies (ie anesthesiology, billing, compliance, payroll, EMR/IT, etc).</p><p>Identify any Quality Reporting (“G-code”) non-compliance.</p><p>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?</p><p>Describe patient wait-times for appointments, and recent trends</p><p>Describe any out-of-network reimbursement ratio, strategy, or trends</p><p>Describe any high-profile, high-marketing, dominant, or noteworthy participants</p><p>Describe any incidents of negative publicity, scandals or media reporting regarding facility or participants</p><p>Describe any other positive or negative issues that you think might affect value</p>