KAM Account Evaluation Intake Form

1. Account Overview

Capture the core account profile, key contacts, and ownership of the evaluation.

Account Name

Location(s)

Key Contact(s)

Role / Title

Date of Evaluation

KAM Owner

2. Practice Structure

Document the shape of the practice, staffing model, and operational ownership.

Number of ENT Physicians

Number of Audiologists

Number of HIS Providers

Number of Locations

Audiology Model

Scheduling Ownership

3. Patient Volume & Flow

Enter current-state funnel assumptions or known account metrics. Use whole numbers or percentages as appropriate.

Annual ENT Patient Visits

% Referred for Hearing Evaluation

% Completing Hearing Test

% Identified with Hearing Loss

% Aidable Candidates

% Scheduled for Consultation

% Converting to Treatment

4. Audiology Performance Metrics

Capture production and commercial performance to compare current state against best practice potential.

Average Units per Patient

Average Selling Price per Unit ($)

Annual Hearing Aid Units Sold

Annual Hearing Aid Revenue ($)

5. Care Pathway Assessment

Identify where patient drop-off occurs and whether time-to-next-step is contributing to leakage.

Where are patients dropping off?

Not referred for testing Do not complete testing Identified but not scheduled for consult Consult completed but no purchase Delayed or lost to follow-up

Average Time: Test to Consult

Average Time: Consult to Fitting

6. Operational Observations

Assess physician engagement, recommendation strength, and handoff consistency.

ENT Physician Engagement in Audiology

Strength of Recommendation for Treatment

Handoff Process from ENT to Audiology

Operational Notes

7. Financial Model

Document ownership structure and reimbursement mix to frame the business case.

Revenue Ownership

% Private Pay

% Insurance / 3rd Party

8. Growth Opportunity Indicators

Flag visible gaps and note the highest-priority levers for improvement.

Observed Gaps

Low testing rate (<50%) Low consult rate (<60% of aidable) Low conversion rate (<60%) Low units per patient (<1.6) Low ASP

Estimated Opportunity Areas

Increase testing volume Improve consult scheduling Improve close rate Optimize pricing / mix Improve ENT engagement

9. Strategic Hypothesis

State your point of view going in. This should reflect the account story, likely bottlenecks, and what you believe is suppressing growth.

KAM Strategic Hypothesis

10. Recommended Next Steps

Define the most appropriate follow-up motion based on account maturity, receptivity, and upside.

Full Funnel Analysis On-site Workflow Observation Pilot Program Executive Business Review Financial Opportunity Model Presentation

Notes / Key Insights