Client intake · 10–15 minutes

What we need from the practice — not the model.

Fill what you know. Blank is fine. Do not include patient names, dates of birth, MRNs or other PHI. Trailing twelve months, aggregated counts only.

Practice

Practice name

City / market

Your name

Title

Phone

Specialty

Physicians

Encounters, trailing 12 months

Data period (e.g. Oct 2025–Sep 2026)

Ancillary book

Ordered = eligible volume. Billed on your TIN = current capture. Leave blank if you need the biller. Skip $ / margin / build cost — that is GHV’s model, not this form.

Physical therapy

Today

PT ordered in the EMR (episodes / new evals — not 97110 units)

97161–97163 billed on your TIN

MRI / advanced imaging

Today

MRI / CT ordered

Technical component billed on your TIN (not 26-only)

Bracing / DME

Today

Braces fitted or ordered in clinic

L- or E-codes billed on your DME PTAN

ASC-eligible surgery

Today

Outpatient cases still at the hospital (POS 22)

Cases already in an ASC you own or economically control (not a JV you dislike)

DEXA / bone health

Today

DEXA ordered (77080 / 77085)

Billed on your TIN

The decision

What should leadership be able to decide after this?

Anything else (capital, JV, space, staffing)

Opens mail to bob.montgomery@greaterhealthventures.com. Aggregated volumes only.