Looking to Purchase a Practice

Acquisition Details

Estimated opening date of the acquired practice

Do you own any other practices apart from the one being acquired?

Yes

If yes, how many do you own and where are they located?

Practice Model & Enrollment

Is your intent post-acquisition to be?

FFS (Fee For Service)

PPO Provider

Have you submitted any PPO applications for the acquired office?

Yes

Did you hold PPO contracts at any previous location(s)?

Yes

Please upload your UCR fees

Membership & Management Systems

Do you intend to offer a membership plan post-acquisition?

Yes

Have you selected a practice management system for the acquired practice?

Yes

If you have selected a practce management system, please specify

Membership & Management Systems - Continued

Will the seller remain as an associate of the practice post-acquisition?

Yes

Unsure

What is the seller’s estimated gross annual revenue?

$250k to $499K

$500k to $749K

$750k to $1.24M

$1.25M to $2.9M

$3M-$5M

$5M +

Was the seller primarily

Fee for Service

Enrolled in Networks

I am not aware

When do you plan to inform the seller’s team about the acquisition?

Immediately, within the next few days

After all legal and financial formalities are completed

One month before the finalized Closing date

I have already informed the team

Other

Membership & Management Systems - Continued

Which networks is the seller credentialed with? (Choose all that apply)

Aetna

Ameritas

Anthem

Blue Cross

Careington

CCPOA

Cigna

Connection Dental

CSEA

Delta Dental Premier

Delta Dental Premier/PPO

Delta Dental PPO

DenteMax

DHA/Sun Life

Diversified Dental Services

DNOA

Emblem

First Dental Health

Guardian

Horizon

Humana

Medical Mutual

MetLife

Paramount

Premier

Principal

Superior

United Concordia

United Healthcare

Zelis/Stratose/Maverest

Unicare

NONE OF THE ABOVE

Feedback & Expectations

Are there any specific challenges or concerns you anticipate with the acquisition?

How did you hear about our consultancy services, and what are your expectations from us during this acquisition process?

Please share any other details or questions you might have about this acquisition.

Contact Information

Acquired Practice's Name

What is the address of the practice you are buying?

Practice's Website

Your role

State your practice is located

Contact Information - Continued

First Name

Last Name

Email *

Phone *

Your time zone?

Preferred Time and Method of Contact