| Type of Facility Desired? |
| Hospital-General | | Hospital-Specialty | | Hospital-Rural | | Surgery Center-Hospital attached & affiliated | | Surgery Center-Free Standing Hospital Affiliated | | Surgery Center- Free Standing Not hospital affilia | | Will consider any Healthcare Facility |
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| Anesthesia Group Name |
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Group Street Address 1 |
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| Group Street Address 2 |
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Group City |
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Group State |
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Group Zip Code |
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| Group Country |
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| Group Voice Phone |
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| Group Fax |
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| Anesthesia Group Web Site |
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| Select states where group is licensed |
| Alabama | | 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 |
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| Does Anesthesia Group have an exclusive contract? |
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| How many first case of the day starts can the Group provide? |
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| Type of Anesthesia Providers desired to be used: |
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| If Medically Directed CRNAs, what level of medical direction is preferred MD: CRNA ratio |
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| Is it ok for Facility to have certified nurse-midwives (CNM) or certified professional midwives (CPM)? |
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| Is an anesthesia provider available at all times to be available for OB coverage? |
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| What level of anesthesia call is available? |
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| What is the total number of anesthetics delivered by the group last year? |
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| What subspecialty certification exists within the group? (Check all that apply) |
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| Will the Group provide OR management services? |
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| Do the nurse anesthetists place epidurals? |
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| Who provides anesthesia for C-sections? |
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| Does the Anesthesia Group want a Stipend? |
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What other services can the Anesthesia Group perform?
(Check all that apply) |
| Other (Specify in Comments) |
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| Can the Anesthesia Group provide a chronic pain service? If so, would the service be hospital based, independent, an ASC, or no preference. (Check all that apply) |
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| Can the Anesthesia Group provide an acute pain service? |
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| Can the Anesthesia Group provide Out-Of-Operating Room (OOOR) anesthesia coverage? |
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| Indicate any other comments you may have |
| This lead physician is extremely well trained and boarded in both Pain and Anesthesia. He is interested in forming a group to cover your ORs and ASCs. They are philosophically opposed to taking a stipend from the hospital. For more information on this group please contact Anthem Associates. |
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