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Medical Group Management Association

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Additional Provider Information

Bonus/Incentive Amount

Indicate the total dollar amount for any bonus or incentive payments received by each provider. It
is important to understand that any bonus or incentive dollar amounts should NOT be included as
percentages of overall productivity.

Retirement Benefits

Report all employer contributions to retirement plans including defined benefit and contribution
plans, 401(k), 403(b) and Keogh Plans, and any nonqualified funded retirement plan. For defined
benefit plans, estimate the employer's contribution made on behalf of each plan participant by
multiplying the employer's total contribution by each plan participant's compensation divided by the total compensation of all plan participants.
Do not include:

  • Employer contributions to social security mandated by the Federal Insurance Contributions Act

  • Voluntary employee contributions that are an allocation of salary to a 401(k), 403(b), or Keogh Plan; or

  • The dollar value of any other fringe benefits paid by the practice, such as life and health insurance or automobile allowances.

Compensation Includes Revenue from Separate Facility Fee

Answer "Yes" if the physician received compensation that could be attributed to a separate facility
fee. This could include compensation from ownership in an ASC or cath lab, for example.

Internal or External Directorship

If you answered yes to “Provider had medical directorship duties,” indicate whether the directorship
was internal or external by choosing the appropriate option from the dropdown box. If the same
federal tax ID is used, the directorship is internal. If a different federal tax ID is used, the directorship
is external. For example, if the physician is employed by his medical practice for his medical
directorship duties, select "Internal." If the physician is a medical director for an organization other
than the one he practices at, select "External."


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