Cost Analysis Survey Input
Organizational Questions
1)  Please select in which AAP Region your service is primarily located. Please note, if you provide a significant amount of service in another AAP Region, you will need to fill in a separate survey for that location.  (Required)
     Region 1 – Armstrong, Butler, Clarion, Crawford, Erie, Forest, Jefferson, Lawrence, Mercer, Venango, and Warren

     Region 2 – Cameron, Centre, Clearfield, Clinton, Elk, Indiana, McKean, and Potter

     Region 3 – Bradford, Carbon, Columbia, Lackawanna, Lehigh, Luzerne, Lycoming, Monroe, Montour, Northampton, Northumberland, Pike, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, and Wyoming

     Region 4 – Allegheny, Beaver, Cambria, Fayette, Greene, Somerset, Washington, and Westmoreland

     Region 5 – Adams, Bedford, Blair, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Mifflin, and Perry

     Region 6 – Berks, Bucks, Chester, Delaware, Lancaster, Lebanon, Montgomery, Philadelphia, Schuylkill, and York

2)  Which category best describes your primary response area?  (Required)
    Rural  * Rural area. - An area outside urbanized areas as defined by the United States Bureau of the Census.
    Urban
    Combination

3)  Your organizational structure is:  (Required)
    For Profit
    Non Profit
    Fire Based
    Hospital Based
    Municipal
    Other   

4)  The level of services offered:  (Required; More than one may be selected.)
    ALS (MICU)
    ALS Squad (All ALS services)
    BLS
    PUC Licensed
    Wheelchair (non PUC licensed)
    Other (please specify)  

5)  Do you provide ambulance service outside of PA?   (Required; If yes, please indicate up to three other states that are served.)
    Yes 
      a) 
      b) 
      c) 
    No 

6)  Please list your 2008 (calendar year) call volume, in whole numbers:

      a)  Total Emergency Ambulance Responses (total dispatched including all
      transports, stand bys, refusals and other no transport calls)     Required; must not be 0
      b)  Number of Emergency Ambulance Patients Transported Required
      c)  Non-Emergency Ambulance Transports Required
      d)  Wheelchair Van Transports
      e)  Other: Please Specify: 

7)  Please outline your organization’s payer mix related to ambulance transports? (% of payers which are billed as the initial primary payer); Required; sum of percentages must equal 100.
Enter 0 if a payer does not apply to your organization.
       % Medicare (including Medicare Advantage / HMO / PPO)
       % Medicaid (including Medicaid HMO / PPO)
       % Commercial (not including Auto or Worker’s Compensation claims)
       % Auto Insurance
       % Worker’s Compensation
       % Private Pay
Cost Analysis Questions
8)  TOTAL UNIT HOURS PER WEEK:
    Estimate the number of hours staffed per week
    (see instructions)     Required; must not be 0
    Manned Ambulance Hours per Week

9)  Expenses:
    A. Total Expenses per Year
    (Include ALL expenses (i.e.: labor, taxes, supplies,
    Billing/ office costs, maintenance, insurance, etc.)
    If depreciation for ambulances, buildings, and other capital equipment is included in line 9a, then enter 0 in lines b, c and d.     Required
$ Total Expenses

    B. Add Depreciation Cost for Ambulance(s)
    (Enter 0 if this cost is already included in line 9a.)
$ Increase for Amb. Depreciation

    C. Depreciation Cost for Building(s)
    (Enter 0 if this cost is already included in line 9a.)
$ Increase for Building Depreciation

    D. Depreciation Cost for Capital Equipment
    (Enter 0 if this cost is already included in line 6a.)
$ Increase for Equip. Depreciation

10)  COST PER CALL ADJUSTMENT:
    A. Bad Debt / Contractual Allowance Adjustment
    e.g.: If your gross collection % is 60%, then add 40% here  (Required)
 % Bad Debt/CA Allowance

    B. Enter Projected Net Revenue or Estimated Profit Margin %  (Required)
 % Net Revenue / Profit Margin


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