Cost of Practice in Hawaii survey

Survey Information

The purpose of this study is to estimate the cost of practicing medicine in Hawaii. Our federal legislators have requested this information in order to encourage Medicare to adjust rates for Hawaii. We will compile your answers and provide the composite data to federal legislative staff. Your participation in this project is completely voluntary. You may stop participating at any time. If you stop being in the study, there will be no penalty or loss to you.

Confidentiality and Privacy: We will not ask any identifying information from you. Your answers will remain anonymous. Other agencies that have legal permission have the right to review research records. The University of Hawai'i Human Studies Program has the right to review research records for this study.

This survey consists of 19 short questions and will require information about the expenses faced by your practice in dollars. Please fill it out to the best of your knowledge.

Questions: If you have any questions about this study, please call or email me at 808-429-8712 or withy@hawaii.edu. You may contact the UH Human Studies Program at 808.956.5007 or uhirb@hawaii.edu to discuss problems, concerns and questions, obtain information, or offer input with an informed individual who is unaffiliated with the specific research protocol. Please visit http://go.hawaii.edu/jRd for more information on your rights as a research participant.Mahalo!

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* 1. Zip Code

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* 2. Specialty / Profession

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* 3. Number of Providers in Practice

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* 4. Method of Reporting Expenses for this survey

Annual

Monthly

Other (please specify)

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* 5. Employee Salaries Expenses (payroll)

Wages

Federal Income Tax

Social Security

Medicare Taxes (FICA)

Federal Unemployment Tax (FUTA)

Hawaii State Income Tax

Hawaii State Unemployment Tax

Employee Health Insurance Costs

Retirement Plan

Other (please specify cost type and amount)

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* 6. General Excise Tax

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* 7. Rent / Mortgage (please specify which, along with amount)

Rent or Mortgage?

Dollar Amount

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* 8. Office Supplies

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* 9. Medical Equipment

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* 10. Vaccines

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* 11. Utilities

Electric

Internet

Phone

Janitorial

Other (please specify cost and dollar amount)

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* 12. Advertising

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* 13. Software

Electronic Medical Records

Practice Management (billing platforms, etc.)

Other (please specify cost and dollar amount)

Cost of Practice in Hawaii survey

Survey Information

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* 1. Zip Code

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* 2. Specialty / Profession

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* 3. Number of Providers in Practice

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* 4. Method of Reporting Expenses for this survey

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* 5. Employee Salaries Expenses (payroll)

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* 6. General Excise Tax

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* 7. Rent / Mortgage (please specify which, along with amount)

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* 8. Office Supplies

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* 9. Medical Equipment

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* 10. Vaccines

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* 11. Utilities

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* 12. Advertising

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* 13. Software

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* 14. HOA Dues

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* 15. Licensing

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* 16. Legal Services

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* 17. Interpreters (Language, deaf, other)

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* 18. Other Expenses Not Included Above (please specify type and dollar amount)

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* 19. Other comments