Download pdf CONFIDENTIAL APPLICATION Please List Your Full Contact Information: Name* Today’s Date Business Name*: Business Phone*: Cell Phone*: Email*: Website*: Street Address*: City*: State*: ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip code*: BUSINESS ASSESSMENT Please rank each of the following business items according to the progress you have made on a scale of 1 to 5 (1 = very little progress, 5 = successful implementation with excellent results) 1. I generate the income I want each month. 12345 6. I have all of the time I want for recreation. 12345 2. I am successful at adding new patients every month. 12345 7. I have an efficient and effective practice staff. 12345 3. I have converted my practice from insurance to a cash basis. 12345 8. I have autonomy to practice medicine on my own terms. 12345 4. I know how to treat patients with bio identical hormones. 12345 9. I am able to take my time with my patients. 12345 5. I have a highly profitable and expanding practice. 12345 10. My patients achieve health and wellness with my current medical protocols. 12345 BACKGROUND INFORMATION Educational and professional qualifications Ethical and legal standing Number of years in medical practice Number of years at current practice and locations Patient panel size (patients seen in the past 24 months) Number of patients seen daily Practice/ Specialty (Family Practice, Internist, OB/GYN, D.O.) Community involvement Conferences Attended/Years A4M – American Academy of AntiAging Medicine ACAM – American College of Advancement in Medicine AAPS – Association of American Physicians and Surgeons PAAS – Pan American Allergy Society Please rank each of the personal assessment items on a scale of 1 to 5 (1 = low to 5 = extreme). 1. Risk Taker 12345 6. Invest in yourself 12345 2. Conservative Values 12345 7. Coachable 12345 3. Aspirational 12345 8. Visionary 12345 4. Process and Goal Oriented 12345 9. Rule Breaker 12345 9. Wellness Centric 12345 10. Flexibility 12345 As part of the application, you will be required to complete several personality assessments, including the Predictive Index and the Kolbe®. These assessments reveal not only your predominant personality traits, but also, how you strive. PRACTICE REVENUE RANGE (Check appropriate box) $250,000 - $500,000$500,000 - $750,000$750,000 - $1,000,000Above $1,000,000 PLEASE TELL US MORE ABOUT YOU 1. Describe your business as it is right now (including what you do, how long you’ve been in business, your income streams, number of patients, size of your medical staff, and size of your back-office support staff). 2. If you are accepted into Hotze Elite Physicians™, what are your top 3 goals you want to accomplish over the next year? 3. What are 3 challenges or obstacles you would like to overcome in your business? 4. What programs or initiatives to improve your practice have you implemented before and what were the results? If they did not work, why not? If they did, why? 5. What is your vison for your practice? 6. What is your financial goal for this year? 7. Please describe why you are an excellent candidate Hotze Elite Physicians™, and what would you be able to contribute to the other members? 8. Is there anything else we need to know as we consider your application? BACKGROUND CHECK DISCLOSURE A consumer report is a background check in which information (which may include, but is not limited to, creditworthiness, credit standing, credit capacity, criminal background, driving background, character, general reputation, personal characteristics, and mode of living) about you is gathered and communicated by a consumer reporting agency (“CRA”) to Braidwood Management and/or its subsidiaries, affiliates, other related entities, successors, and/or assigns (the “Company”). Company may obtain a consumer report on you to be used for employment purposes. BACKGROUND CHECK AUTHORIZATION(Please read and sign this form in the space provided below. Your written authorization is necessary for procurement of a background check for Braidwood Management and/or its subsidiaries, affiliates, other related entities, successors, and/or assigns (the “Company”).) I, ,hereby authorize Company to procure a consumer report as described in the Background Check Disclosure. I understand that Company will utilize a consumer reporting agency to procure a consumer report, and I specifically authorize such an investigation by a consumer reporting agency and outside entities of Company’s choice. My authorization remains valid throughout my employment with the Company, such that, to the extent permitted by applicable law, I agree Company can procure additional consumer report(s), criminal background check(s), and/or consumer credit report(s) during my employment without providing additional disclosures or obtaining additional authorizations. Applicant’s Name - Printed Date Send
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