Spreadsheet: 44bcfe7d-0637-43d8-b00b-cdbe1db99534
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | SAMPLE PRO FORMA FOR DRIVING PROGRAM | Key Metrics | Unnamed: 4
 | Yr 1 | Notes | Yr 1
Revenue
Evaluations | 0 | Projected volume of evaluations & based at rate of $x for an evaluation, conference & report . |  | projected volume of service
 |  | Rate can be set per service provided or by an hourly rate. Note that this formula is based on a rate per service. |  | rate per service provided
 |  | *Add in any additional services you expect to provide in your program.
Bad Debt | 0 | Bad debt for not-sufficient-fund checks and credit cards figured at x% of total. |  | % of deduction for bad debt
 |  | *Add in any additional payer types expected to reimburse for driving services.
Discount - PPO | 0 | Identify percentage of business expected per payer type and typical reimbursement as a percentage of charges. |  | % of volume expected from payer type
 |  |  |  | % of discount from charges
Discount - HMO | 0 | Identify percentage of business expected per payer type and typical reimbursement as a percentage of charges. |  | % of volume expected from payer type
 |  |  |  | % of discount from charges
Discount -Workers                        Compensation | 0 | Identify percentage of business expected per payer type and typical reimbursement as a percentage of charges. |  | % of volume expected from payer type
 |  |  |  | % of discount from charges
Discount - Cash |  | Identify percentage of business expected per payer type and typical reimbursement as a percentage of charges. Use this if cash discount is given. |  | % of volume expected from payer type
 |  |  |  | % of discount from charges
Total Net Revenue | 0 | Total of revenue for all services minus bad debt and discounts.
Expenses
[NAME]
Salaries | 0 | If services to be provided by an employee, project total hours for volume of services projected for the year multiplied by the hourly rate of the employee. |  | hourly rate for employee
 |  | Identify the hours needed to produce the evaluation or service provided. |  | hours projected to deliver services
Benefits | 0 | Cost of benefits can be expressed differently in various organizations.  [NAME] is based on benefits expressed as a per cent of salaries |  | benefit rate as a % of salaries
Total Salary Expense | 0
Other Non-Salary Expenses |  | Identify all expenses outside of salaries. Make note of those expenses that will occur only for start-up as these will not be included from year 2.
Supplies |  | Cost out any supply items needed such as testing materials, adaptive equipment, office supplies, etc. Annotate any expenses that will be one-time only for start-up.
Clinic Supplies
Minor Equipment
Office Supplies
Other
Other
Purchased Services | 0 | If services are to be provided by a contractor, project total hours for volume of services projected for the year multiplied by the hourly rate of the contractor. |  | hours projected to deliver services
Car Maintenance |  | Add in other purchased services and annotate for any start-up expenses. |  | hourly rate for contractor
Insurance
Gasoline
Remodeling Expenses
Telephone
Utilities - Gas, Water,                                                  Electric
Entertainment, Food
Training Expenses
Travel Expenses
Tax and License Fees
Other
Other
Rents and Leases |  | Identify expenses for rental or lease of space or equipment.
Other Indirects |  | Some organizations provide an additional allocation to departments of such costs such as workers compensation insurance. Find out if this needs to be included in your organization.
Depreciation |  | Some organizations add in depreciation of capital assets over the projected life of the equipment as part of the expense equation.
Total Non-Salary Expenses | 0
DIRECT EXPENSE | 0 | Sum of salary expenses and non-salary expenses
CONTRIBUTION MARGIN | 0 | Total net revenue minus direct expenses
 |  | Key metrics are identified in column to the right. Changes to any metric will significantly change the model.
INDIRECT COST ESTIMATE | 0 | Additional cost of overhead added on by the corporation. |  | Percent markup on direct cost
TOTAL COST MARGIN | 0 | Contribution margin minus indirect cost estimate.