Results and Recognition Program Contact Form

Results and Recognition Contact Form

Information needed to communicate and process incentive payments.

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* 1. Practice name:

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* 2. Main contact name

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* 3. Address for check to be sent:

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. Service Address (please complete if not the same as above):

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Tax ID:

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* 6. Fax number:

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* 7. Which means of communication is preferred? Check all that apply

Fax

Email

Phone

Mail

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* 8. Practice information:

What EMR system do you use:

Does your practice have care coordination:

Are you part of a health system and/or an ACO/CIN (please list):

Do you have multiple sites (please list):

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* 9. Are you enrolled in EFT for payments?

Yes

No