HSAG-AAFP METRIC Hypertension Study - Training Session I: Verification Survey

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HSAG-AAFP METRIC Hypertension Study - Training Session I: Overview and Timeline

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* 1. Please enter the following information for your physician practice. (All fields are required.):

Physician Practice: *

Address: *

City/Town:

State:

ZIP/Postal Code:

Phone Number: *

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* 2. Please enter the following information for the primary person in your practice who will be responsible for preparing and sending the Master List of potentially eligible patients to HSAG. (All fields are required.):

Name and Credentials:

Title

Email Address:

Phone Number:

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* 3. What is the date that the above-named person (from question 2) viewed this training session (mm/dd/yyyy)?

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* 4. Please enter the following information for the person HSAG should contact if we have questions related to your Master List of eligible patients?

(If this is the same person, enter "same" in the Name and Credentials box and go to the next question. If this not the same person, please fill out all fields.)

Name and Credentials: *

Title:

Email Address:

Phone Number:

Question Title

* 5. Please enter the following information of the primary person in your practice who will be responsible for completing the medical record chart reviews?

(If this person is listed above, enter "same as #2" or "same as #4" in the Name and Credentials box and go to the next question. If this not the same person, please fill out all fields.)

Name and Credentials: *

Title:

Email Address:

Phone Number: *

Question Title

* 6. What is the date that the above-named person (from question 5) viewed this training session (mm/dd/yyyy)?