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* 1. Please enter your contact information.

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* 2. Please describe your practice setting:

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* 3. Please submit a Word file with all of the National Provider Identifiers (NPIs) of the physicians (owners and employees) and other clinical staff employed by your practice who bill the fee-for-service Medicare program for their services.

This file can be in either .doc or .docx format. Please name your document using the following format:

YourPracticeName_state_NPI

For example, the file name for ABC Oncology in New Jersey would be: ABCOncology_NJ_NPI.docx

Please be sure to use the exact same practice name as entered above.

Within this file, the NPIs should each be on their own line, like so:

1234567890
2345678901
3456789012
...

If you have questions, please contact David.Harter@asco.org.

DOC, DOCX file types only.
Choose File

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* 4. What is the percentage of total practice revenue/collections (in dollars) for Medicare fee-for-service patients?

Please enter this percentage as a whole number between 0 and 100, rounded to the nearest percent.

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* 5. What is the percentage of the practice’s patients that are fee-for-service Medicare beneficiaries?

Please enter this percentage as a whole number between 0 and 100, rounded to the nearest percent.

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* 6. Please provide the total number of full time equivalents (FTE) that provide services to patients for both Medicare and non-Medicare beneficiaries.

All entries should be in numerical form; one decimal place will be accepted.

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