AmeriHealth Caritas North Carolina Data Sharing Survey

1.Please provide the following information about your practice.(Required.)

Practice Name

Practice TIN

Street Address

City

State

Zip code

Name of individual responsible for Medical Records

Title of individual responsible for Medical Records

Phone number

Fax number

2.Do you use a third-party vendor for Medical Records management?(Required.)

Yes

3.If you answered yes to Q2, please provide primary contact information for your third-party vendor. If no, proceed to Q4.

Vendor Company name

Contact name

Contact title

Phone number

Fax number

4.Do you use an EMR Vendor?(Required.)

Yes

If yes, please provide the name of your current EMR vendor.

5.Please let us know (by checking the box) if AmeriHealth Caritas North Carolina can follow up with your practice about the following:

Granting AmeriHealth Caritas North Carolina direct access to your EMR for medical record retrieval.

Learning more about ongoing supplemental data exchange.