Thank You for your interest in HealthPRO.   
Please complete the form below, so we can begin our analysis and develop a proposal to meet your therapy needs.    
Facility Name:   Contact Person:  
Facility Address:        
City:   State:         Zip:  
Phone:   Fax:  
Email:  
Number of Skilled Nursing Beds:  
Number of Medicare A Beds:  
Other Beds:  
Type of Therapy Program:  
Therapy Company:  
Contract Therapy Pricing Model:  


Please Check all HealthPRO Services which interest you    
Guaranteed Cost/Minute Model    Inhouse Management Model with Guaranteed Savings/Staffing
Flat Fee Management Model Inhouse Management Model with Set Fee per month
Computer Management Model HealthMAX Computer System with Fiscal/Outcome Reports/Analysis
Affinity Full Service Contract Model Full Contract Therapy Model with HealthPRO Oversight
Affinity to HealthPRO Model Start with Affinity then Convert to HealthPRO for further savings
Therapy Staffing Supplemental Staffing provided on a Cost/hour basis
Other:    You tell us what you want/need


(Please Indicate Ave Units/Month, Ave Days/month per RUG, Current RUG Rates, & Contract Rehab rates if applicable)
  Therapy Utilization
  PT OT SLP
Med A   
Med B   
HMO   
Other   
Total   


  Contract Rehab Contract Rates
  Cost/Minute Per Diem % of HCPCS Other
HMO 
Med B 
Medicaid 
Other 
Medicare A
  Avg. Days/Month Current Med A Rate/day If Contract, Rehab Per Diem
RUC   
RUB   
RUA   
RVC   
RVB   
RVA   
RHC   
RHB   
RHA   
RMC   
RMB   
RMA   
RLB   
RLA   
How soon would you like to meet with us to review your proposal?