Thank you for your interest in Rehab Management, Inc. Therapy Services.

To help RMI prepare an accurate proposal or cost analysis of your current rehabilitation program we need some information about your current utilization and program needs.

It will be necessary for anyone requesting a pricing proposal or a profitability analysis of your current therapy services, to fill out this provided form in its entirety.

If additional information is requested, please fill out the top portion of this form along with the information box at the bottom of the page identifying what information is needed. Your requests will be responded to promptly. Alternatively you may print and complete this form and fax it to Vaniene Hardy at (804) 379-9269. If you have questions, please call (800) 969-9265 ext. 146 or e-mail vaniene@rehabmanagement.com.

* Indicates a mandatory field

*Facility Name:
*Contact Name:
Address:
City:
State:	[Choose One] 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	Zip:
*Phone:		Fax:
*Email:

  
 

Number of licensed beds for each category:
Skilled Nursing:		Assisted Living:
Independent:		Nursing:

 
  

Average Days Per Month Per RUGS Category :
Ultra High (720 minutes):
Very High (500 minutes):
High (325 minutes):
Medium (150 minutes):
Low (45 minutes):
HCPCS used monthly:
PT hours worked per month:
OT hours worked per month:
ST hours worked per month:
Classification:   Urban    Rural
What timeframe are you considering for a decision?   ASAP    30 days    60 days
Are there any other programs or services you would like RMI to consider in the proposal?