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| PATIENTS AND ENCOUNTERS IN THE CALENDAR YEAR (ALL CLINICS) |
| Please report the total number of individual, unduplicated patients served and the total number of encounters for these patients. Please refer to the instructions for further details. |
Line
No. | | (1)
Unduplicated Patients | (2)
Encounters |
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| 1. | Total, all locations under this license (Main, Mobile, Satellite, etc.) | 381 | 427 |
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| SURGICAL CLINICS ONLY |
Line
No. | | (1)
Number |
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| 5. | Number of surgical operating rooms on December 31 | 2 | | 6. | Total number of surgical operations performed during the calendar year | 427 | | 7. | If you provided abortion services directly at your clinic, provide the total number of abortions performed | 0 |
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| PSYCHOLOGY CLINICS ONLY |
Line
No. | Service Type | (1)
Encounters |
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| 11. | General Medical | 0 | | 12. | Substance Abuse (alcohol and drug) | 0 | | 13. | Mental Health Counseling | 0 | | 14. | All Other | 0 | | 15. | Total | 0 |
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| INCOME STATEMENT |
Line
No. | | (1)
Total |
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| 1. | Gross Patient Revenue | $293,819 | | WRITE-OFFS AND ADJUSTMENTS: | | 2. | Charity | 0 | | 3. | Contractual Adjustments | 0 | | 4. | Bad Debts | 0 | | 8. | Other Adjustments | 0 | | 9. | Total Write-Offs and Adjustments (line 2-8) | $0 | | 10. | Net Patient Revenue (line 1 minus 9) | $293,819 | | Other Operating Revenue: | | 11. | Grants - Public | 0 | | 12. | Grants - Private | 0 | | 13. | Donations / Contributions | 0 | | 19. | Other | 0 | | 20. | Total Other Operating Revenue (sum lines 11 - 19) | $0 | | 25. | Total Operating Revenue (line 10 + Line 20) | $293,819 | | Operating Expenses: | | 30. | Salaries, Wages and Employee Benefits | $125,184 | | 31. | Contract Services - Professional | $9,979 | | 32. | Supplies | $74,518 | | 33. | Rent / Depreciation / Mortgage Interest | $8,653 | | 34. | Utilities | $2,063 | | 35. | Professional Liability Insurance | $4,417 | | 36. | Other Insurances | $6,761 | | 44. | All Other Expenses | $34,232 | | 45. | Total Operating Expenses (sum lines 30 - 44) | $265,807 | | 50. | Net From Operations (line 25 minus Line 45) | $28,012 |
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The Clinic's License Fee Will Be Based Upon The Completion Of This Income Statement And Will Be Calculated Accordingly. |
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| | Section 127285(3) of the Health and Safety Code requires each clinic to report "acquisitions of diagnostic or therapeutic equipment during the reporting period with a value in excess of five hundred thousand dollars ($500,000)." |
| | Diagnostic and Therapeutic Equipment Acquired During The Report Period |
| 1. | Did your clinic acquire any diagnostic or therapeutic equipment that had a value of $500,000 or more? (If 'Yes', fill out lines 2 through 11 below.) | No |
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| | Diagnostic and Therapeutic Equipment Detail |
Line
No. | (1)
Description of Equipment | (2)
Value | (3)
Date of Aquisition
MM/DD/YYYY | (4)
Means of Acquisition |
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| 2. | | 0 | | | | 3. | | 0 | | | | 4. | | 0 | | | | 5. | | 0 | | | | 6. | | 0 | | | | 7. | | 0 | | | | 8. | | 0 | | | | 9. | | 0 | | | | 10. | | 0 | | | | 11. | | 0 | | |
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| | Building Projects Commenced During Report Period Costing Over $1,000,000 |
| | Section 127285(4) of the Health and Safety Code requires each clinic to report the "commencement of projects during the reporting period that require a capital expenditure for the facility or clinic in excess of one million dollars ($1,000,000)." |
| 25. | Did your clinic commence any building projects during the report period which will require an aggregate capital expenditure exceeding $1,000,000? (If 'Yes', fill out lines 26 through 30 below.) | No |
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| | Detail of Capital Expenditures |
Line
No. | (1)
Description of Project | (2)
Projected Total Capital Expenditure | (3)
OSHPD Project No.
(if applicable) |
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| 26. | | 0 | | | 27. | | 0 | | | 28. | | 0 | | | 39 | | 0 | | | 30. | | 0 | |
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