COVID-19 Revenue and Cost Impacts

Please have only one person per entity complete this survey.

1. Contact Information *This question is required.

Provider Name/Entity
Contact Person
Contact Phone Number
Contact Email Address

2. Please indicate the service represented (check all that apply) *This question is required.

General Therapy
Intensive Outpatient
Peer Recovery Support
Medication Assisted Treatment
Partial Hospitalization
Residential Treatment
Other, please specify Please enter an 'other' value for this selection.
My entity also provides mental health care services

3. Please indicate the type of provider *This question is required.

4. This Section is about Revenue trends - measured by your daily or weekly billings in month
Instructions: - Use Fee For Service Billing/Gross Charges to indicate impact in each of the following payer classes.
*This question is required.

Space Cell	Commercial Insurance Billed Revenue	Medicare Billed Revenue	Medicaid Billed Revenue	Self Pay Billed Revenue	Total Insurance Billed Revenue
Jan (Jan 2020)	Jan (Jan 2020): Commercial Insurance Billed Revenue	Jan (Jan 2020): Medicare Billed Revenue	Jan (Jan 2020): Medicaid Billed Revenue	Jan (Jan 2020): Self Pay Billed Revenue	Jan (Jan 2020): Total Insurance Billed Revenue
Feb (Feb 2020)	Feb (Feb 2020): Commercial Insurance Billed Revenue	Feb (Feb 2020): Medicare Billed Revenue	Feb (Feb 2020): Medicaid Billed Revenue	Feb (Feb 2020): Self Pay Billed Revenue	Feb (Feb 2020): Total Insurance Billed Revenue
Mar (March 2020)	Mar (March 2020): Commercial Insurance Billed Revenue	Mar (March 2020): Medicare Billed Revenue	Mar (March 2020): Medicaid Billed Revenue	Mar (March 2020): Self Pay Billed Revenue	Mar (March 2020): Total Insurance Billed Revenue
Apr (April 2020)	Apr (April 2020) : Commercial Insurance Billed Revenue	Apr (April 2020) : Medicare Billed Revenue	Apr (April 2020) : Medicaid Billed Revenue	Apr (April 2020) : Self Pay Billed Revenue	Apr (April 2020) : Total Insurance Billed Revenue

5. This section is about Medicare Stimulus Funds *This question is required.

	Did your Entity Receive Medicare Stimulus Funding? (Y = Yes, N = No)
	If yes, how much Medicare Stimulus Funding was received? (Enter amount or N/A)
	On which date was such funding received? (Enter date or N/A)

6. This section is about the Payroll Protection Program and Unemployment

	Did your entity qualify for Payroll Protection Program (PPP)? (Y = Yes, N = No)
	If yes, how much did you receive from the Payroll Protection Program? (Enter amount or N/A)
	On which date was such funding received? (Enter date or N/A)
	If you did not file for PPP, did you file for unemployment? (Y = Yes, N = No)
	If you filed for unemployment, how many people in your entity filed for unemployment? (Enter number)

7. This section is about events you or your entity may have had to change as a result of the COVID crisis
* Note: Events may include planned education sessions, conferences, Continuing Education, etc
** Please only respond if added costs or lost revenue has occurred as a result of the COVID crisis or Emergency Order

	Did your entity plan any event that you had to cancel as a result of the crisis? (Enter amount or N/A)
	If yes, and the event produced revenue, how much was lost? (Enter amount or N/A)
	If yes, and the event made you incur costs that you can't recover, how much? (i.e travel, registration fees, etc.) (Enter amount or N/A)

8. This section is about added costs resulting from the COVID crisis

	Did your entity invest in technology to deal with the COVID 19 Crisis? (i.e. Telehealth support, EMR licenses, Zoom, telephone, etc.) (Y = Yes, N = No)
	If yes, please indicate the dollar investment made to support the above (Enter amount or N/A)
	Did your entity purchase Personal Protection Equipment (PPE)? (Y = Yes, N = No)
	If yes, please indicate the dollar investment made for PPE (Enter amount or N/A)
	Have you hired additional staff resulting from this COVID-19 Crisis? (Y = Yes, N = No)

9. Costs continued: if you have hired additional staff as a result of the COVID-19, what type of staff did you hire and how many of each did you hire?
* Please only respond if you have hired additional staff as a result of the COVID crisis or Emergency Order

	What is the amount of costs (salary & benefits) for those staff? (Enter amount)
	How many staff in total were hired? (Enter number)
	CRSW (Enter number)
	LADC (Enter number)
	MLADC/LCMHC/LICSW (Enter number)
	MD (Enter number)
	Business/Operations (Enter number)
	Other (Please specify and enter number)

10. Staff Impacts: Describe the dollar value of any cuts/reductions ALREADY made in the following areas

	Personnel Layoffs (Enter amount)
	Personnel Furloughs (Enter amount)
	Benefit Reductions (Enter amount)
	Pension Reductions (Enter amount)
	Other (Enter amount and please briefly describe)

11. Staff Impacts: Describe the dollar value of FURTHER cuts/reductions necessary to survive through October

Personnel Layoffs (Enter amount)
Personnel Furloughs (Enter amount)
Benefit Reductions (Enter amount)
Pension Reductions (Enter amount)
Other (Enter amount and please briefly describe)

12. This section is available to describe other COVID-19 impacts not noted above. Please only add items in this section that can be quantified with real $.