Medicare Survey

The U.S. Department of Health and Human Services (HHS) is asking the chiropractic profession for information that will be used in the development of a new fee scale (please see article on page three). In order to be included in the new proposed rule this information must be collected, tabulated, and reported to the HHS's Office of Payment Policy by JANUARY 31, 1991.

Please complete and mail the survey below immediately to:

MPI - HHS Survey
P.O. Box 6100
Huntington Beach, CA 92615

All surveys must be mailed by January 7, 1991.

Your decision to participate will affect chiropractic's inclusion in Medicare!

SURVEY FOR THE DEPARTMENT OF HEALTH AND HUMAN SERVICES' NEW MEDICARE FEE COMPUTATIONS

(all information will be kept strictly confidential)

Please print clearly. This survey must be completed and mailed by January 7, 1991.

City ____ State ____

1. What is your estimated annual revenue? ____
   


2. What is your estimated annual overhead? ____
   


3. What is your estimated annual malpractice insurance cost? _____
   


4. What is your estimated annual continuing professional education cost? ____
   


5. How many employees do you have? ____
   


6. How many chiropractors practice in your office? ____
   


7. What is your estimated annual employee salary? ____
   


8. What is your average cost for an initial office visit? _____
   


9. What is you average cost for a routine manipulation-only office visit? _____
   


10. What is your average cost for a routine office visit providing manipulation and physiotherapy? ____
    


11. What is your average cost of new patient x-rays? _____