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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.) | 236 | 1,145 |
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| SURGICAL CLINICS ONLY |
Line No. | | (1) Number |
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| 5. | Number of surgical operating rooms on December 31 | 0 | | 6. | Total number of surgical operations performed during the calendar year | 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 | $727,400 | | WRITE-OFFS AND ADJUSTMENTS: | | 2. | Charity | $0 | | 3. | Contractual Adjustments | $33,000 | | 4. | Bad Debts | $31,000 | | 8. | Other Adjustments | $29,000 | | 9. | Total Write-Offs and Adjustments (line 2-8) | $93,000 | | 10. | Net Patient Revenue (line 1 minus 9) | $634,400 | | 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) | $634,400 | | Operating Expenses: | | 30. | Salaries, Wages and Employee Benefits | $196,700 | | 31. | Contract Services - Professional | $10,900 | | 32. | Supplies | $55,000 | | 33. | Rent / Depreciation / Mortgage Interest | $27,500 | | 34. | Utilities | $6,500 | | 35. | Professional Liability Insurance | $33,600 | | 36. | Other Insurances | $6,500 | | 44. | All Other Expenses | $117,000 | | 45. | Total Operating Expenses (sum lines 30 - 44) | $453,700 | | 50. | Net From Operations (line 25 minus Line 45) | $180,700 |
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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 in excess of $500,000? (If 'Yes', fill out lines 2 through 11, as necessary, 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. | | | | | | 3. | | | | | | 4. | | | | | | 5. | | | | | | 6. | | | | | | 7. | | | | | | 8. | | | | | | 9. | | | | | | 10. | | | | | | 11. | | | | |
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| Building Projects Commenced During Report Period Costing Over $1,000,000 |
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| 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, as necessary, 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. | | | | | 27. | | | | | 28. | | | | | 29. | | | | | 30. | | | |
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