Professional Documents
Culture Documents
I. GENERAL INFORMATION
1st Year
Fee per Quantity of
Services Rendered Service Services
B. Page 1 of 12
Financial Summary
In the 2nd year of my business operations, I expect the following percentage increases/
decreases in the fees and quantities from my 1st year estimates of the services I provide:
2nd Year
% Inc./Dec % Inc./Dec
Services Rendered in Fees in Quantity New Quantity
B. Page 2 of 12
Financial Summary
In the 3rd year of my business operations, I expect the following percentage increases/
decreases in the fees and quantities from my 2nd year estimates of the services I provide:
3rd Year
% Inc./Dec % Inc./Dec
Services Rendered in Fees in Quantity New Quantity
Receivables
B. Page 3 of 12
Financial Summary
Discounts/Allowances
List Top Medical Insurance Carriers utilized by your patients. Specify the percentage of
procedures per year that will be covered by these carriers and the average discount that you
offer these carriers on each procedure.
Note: Discounts to self-pay patients can also be listed and treated similarly in this section.
In a corporation, all personal finances of the major stockholders are kept separate from the
finances of the corporation itself.
Therefore, please remember that if your practice is incorporated, all additional revenue sources
must directly relate to the finances/operations of your medical practice.
You may not include personal sources of income if your practice is incorporated.
1st Year
Annual
Source of Revenue Income
Nursing home service 6,000
B. Page 4 of 12
Financial Summary
Listed below is a summary of the employees of my business and their annual salaries
during the first year of operation:
I expect to incur the following dollar expenses related to payroll taxes per year:
B. Page 5 of 12
Financial Summary
I expect to incur the following dollar expenses related to payroll benefits per year:
I expect to employ the services of the following outside professionals at the stated
fees during my first year of business:
Monthly
Service Individual/Firm Fee
Accounting Old McDonald's Accounting $400
Legal Smith & Jones Legal 200
Insurance PICA 1,600
Billing A&B Billing 500
Other
I expect the fees for these services to increase/decrease by the following percentage
for each of the following years:
I expect to incur the following expenses for rent during the first year of business:
Monthly
Type of Rental Expense
Building $1,500
Equipment 450
Other 500
B. Page 6 of 12
Financial Summary
Listed below is a prediction of what my utilities expenses will be for my first year of operation:
Monthly
Type of Utility Expense
Telephone $200
Electricity 250
Gas 200
Water 100
General Waste Removal 200
Bio-Hazardous Waste Removal 200
Maintenance/Cleaning 400
Lab Fees 800
Other 125
Listed below is a prediction of what my monthly expenses will be for office supplies
during the first year of operation.
Monthly
Type of Office Supply Expense
Clinical Supplies $ 1,200
Billing Forms 200
Postage 125
Stationary 175
Software/Hardware 200
Service Contracts 400
Computer Supplies 250
Uniforms 350
Miscellaneous 300
B. Page 7 of 12
Financial Summary
Listed below is a prediction of what my monthly expenses will be for advertising and
promotions during the first year of operation.
Monthly
Type of Advertising Expense
Yellow Pages $100
Newspaper Ads 150
Brochures 200
Radio Ads 600
Signs 100
Promotional Items 125
Customer Service 250
Other 50
B. Page 8 of 12
Financial Summary
I expect to incur the following expenses during my first year of operations to promote
further education.
Monthly
Type of Expense Expense
Continuing Education $250
Professional Journals 100
Subscriptions 125
Employee Education 100
Travel/Meals 50
Other 75
In order to finance my practice I will need to acquire a loan(s) from a lending institution.
It is assumed that the loan payments will be made on a monthly basis and the first
payment will be made at some point during the first year of business operations.
Listed below are the contractual stipulations of my loan agreement:
Loan #1 - Mortgage
This loan should represent only the amount of money needed to purchase your building.
If you are renting your facilities, you do not need to fill in this data.
B. Page 9 of 12
Financial Summary
Amount of Loan
Annual Interest Rate
Term in Years
Month of First Payment (Please type full name of month, ex. January)
Month/Date/Year of First Payment (ex.01/01/98)
XII. TAXES
I expect to pay the following percentage towards combined federal, state and local
income taxes each year:
1st Year 2nd Year 3rd Year
Percentages Percentages Percentages
Federal Taxes 25% 30% 35%
State Taxes 7% 8% 9%
Local Taxes 3% 4% 5%
Estimated
Type of Life of the
Asset Cost Asset
Building
Medical Equipment
Exam Table and Chairs 12,000 5
Exam Lights 900 3
Autoclave 3,600 5
Casting Table 750 3
Cast Cutter 800 3
X-ray Machine 7,000 10
X-ray Processor 4,000 10
Radiographic View Boxes 520 3
Podiatric Instruments 2,500 5
Other Medical Equipment (fill in the cost and expected life)
Jacuzzi 2,500 3
B. Page 10 of 12
Financial Summary
Office Equipment
Office Chairs 1,500 3
Desks 4,500 5
Computer/Software 2,500 3
Printer 1,200 3
Copy Machine 1,800 5
Reception Room Furniture 2,800 7
Supply Cabinets 1,200 5
File Cabinets 1,330 7
Telephone System 4,500 10
Other Office Equipment (fill in the cost and expected life)
* Note - If you are leasing any of the above office space or equipment, do not
include these amounts in your capital budget. They should fall into the
category of rented buildings or equipment.
Facility Remodeling
Reception Area
Office Area
Exam Rooms
Bathroom
Outdoors
Other
B. Page 11 of 12
Financial Summary
In addition to the above capital requirements, I will also need additional short-term (working)
capital to finance my first few months of operations. Listed below are these
requirements:
Sources Amount
Personal Financing
Bank Financing 106,000 <= Should equal => $ 106,000
Other Financing
Any additional cash the business may have will be invested on a short term basis and
earn an approximated annual return of:
B. Page 12 of 12