Provider Support Request Form

Practice Information

Question Title

* 1. Please complete the organizational information below.

Practice Name:

Number of Locations:

Practice Tax ID (FEIN):

Organizational NPI:

Practice City, per site:

Practice Zip Code, per site:

Primary EHR Implementation Contact:

Primary EHR Implementation Contact Telephone:

Primary EHR Implementation Contact Email:

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* 2. Please provide the number of eligible providers in each provider category below:

Family Practice:

Certified Nurse Midwife:

Dentist:

General Practice:

Internal Medicine:

Nurse Practitioner:

OB-GYN:

Pediatrics:

Physician Assistant:

Other Specialty (Please List)

Question Title

* 3. How do you describe your practice setting? (Please check all that apply)

	Please Check
Private Practice (10 or less providers)	Private Practice (10 or less providers) Please Check
Private Practice (11+ providers)	Private Practice (11+ providers) Please Check
Community Health Center (FQHC)	Community Health Center (FQHC) Please Check
Rural Health Clinic (RHC)	Rural Health Clinic (RHC) Please Check
Are you part of a health system?	Are you part of a health system? Please Check
Are you part of an ACO?	Are you part of an ACO? Please Check
Are you participating in a PCMH or Care Coordination program?	Are you participating in a PCMH or Care Coordination program? Please Check
Are you participating in a PQRS program?	Are you participating in a PQRS program? Please Check

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* 4. EHR status

	Please Check One.
Our Practice is Currently Live on a Certified Electronic Health Record Technology (CEHRT).	Our Practice is Currently Live on a Certified Electronic Health Record Technology (CEHRT). Please Check One.
Our Practice is not Currently Live on a Certified Electronic Health Record Technology (CEHRT).	Our Practice is not Currently Live on a Certified Electronic Health Record Technology (CEHRT). Please Check One.
Unknown.`	Unknown.` Please Check One.

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* 5. If your practice is live on certified electronic health record technology (CEHRT), please complete the following:

Name of the CEHRT vendor:

Name of CEHRT product:

Version of the CEHRT:

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* 6. Do you accept Medicare patients?

Yes

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* 7. How many providers are Medicaid eligible for the EHR Incentive Program (greater than 30% encounter volume; greater than 20% encounter volume for pediatrics)?

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* 8. How many of your providers are currently registered in a CMS EHR Incentive Program?

Medicare:

Medicaid:

Question Title

* 9. What do you need assistance with? (Please check all that apply)

Registration with an EHR Incentive Program

AIU (Adopt, Implement, Upgrade) to an EHR System

Meeting Meaningful Use requirements

Education and Training

Other

Other (please specify)

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* 10. Completed by:

Name:

Phone:

Email Address: