HFS CMT: Ambulatory and Community Provider Survey

Please provide information regarding your facility.

1.Facility Type(Required.)

2.Facility Name:
(Required.)

3.Facility Address:(Required.)

Street Address:

City:

State:

Zip Code:

4.Provider Information:(Required.)

NPI:

Provider Number:

All Provider IDs:

5.Name of Person Completing the Survey
(Required.)

Name:

Title:

Email Address:

Phone Number:

6.Person to contact regarding onboarding requirements to the HFS ADT system (if different than above)

Name:

Title:

Email Address:

Phone Number:

7.Additional contact to participate in the onboarding process

Name:

Title:

Email Address:

Phone Number:

8.Are you a part of a larger system/group of facilities? If so, please indicate the name of the system/group.(Required.)

9.Will your facility be sending patient roster files at the group level or at your individual facility?(Required.)

10.When will your facility be ready to onboard?
(Required.)

11.Does your facility have a current EHR system?(Required.)

Thank you for completing the survey. HFS will be contacting you shortly with an onboarding package to explain the next steps when your facility is ready to connect with the HealthChoice Illinois ADT system.