Work State/Province/Region
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Work Country
United States
Canada
States
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Home Country
United States
Canada
Names and Percentages of Reduced Fee Programs:
The Last 3 Business Tax Returns
Copy Of Profit And Loss – Current And Most Recent Year
Fee Schedule(s) for cash/creditand top three insurances if
different
Equipment List (if available)
Accounts Receivable Aging Report (30, 60, 90, over 90---Totals
only)
Monthly production and collection totals only for current
year
Current and Previous year -Production by Procedure Code
Report
Last full year -Revenue listed by cash/credit and by each
insurance company
Associate Agreement and theirwages and production total–Current
and Previous Year
Copy of Office Lease (if applicable)
If applicable, Partnership Agreements