Free In-House Evaluation | Rehab Management

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 Ken Sandy at 804-419-1566. If you have questions, please call (800) 969-9265.

*Facility Name:

*Contact Name:

Address:

City:

State:

Zip:

*Email:

*Phone:

Fax:

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:

SLP 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?