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       Easy as 1, 2, 3.
         * Indicates a required field
         (If an item does not apply please enter zero)
Step 1: Please Enter Your Key Information (preferred but not required)            
Name of Your Organization      Email          
Your First And Last Name        Phone #      
Step 2: Please Enter Your Key Data Click here to email for help with this form  
* Average Gross Revenue per Inpatient Admission $     * Market Share in Primary Service Area %  
* Average Gross Revenue per Outpatient Visit $ * Managed Care Discounts and Bad Debt %
* Average Gross Revenue per ER Visit $     * Variable Cost per Case or Discharge %  
* % of ER Patients Admitted as Inpatients %     * Contact Center Direct Operating Cost $  
          * Direct Revenue Generated or Revenue Recovered $  
Step 3: Please Enter Your Contact Volume:                
* Total Number of Inbound and Outbound Phone Calls   * Total Number of Class Registrations, Physician Referrals via the Web Annually    
 For your estimated financial benefit