Application for NCAHEC's Primary Care Consulting Services

Required fields are marked with an asterisk (*)

Entity / Organization Information

What is your Tax ID Number? * -     
What is the legal business name associated with this tax ID number? *
How many geographic locations (sites) that perform primary care are covered by this tax ID? *
What is the business address associated with this tax ID?
Address *
City *  State *  Zip Code *
Phone *
999-999-9999		  Fax
Email

Practice Information

Practice Name *
Address *
City *    State *
County *    Zip Code *
Phone *
999-999-9999		 Fax
Email

Practice Contact

First Name *
Last Name *
Title
Address
City State Zip Code
Phone *
999-999-9999		 Fax
Email *

Practice Details

How many prescribing providers are in your practice?
How many patient encounters per year? (Estimate) *
How many unique patients per year? (Estimate) *
Patient insurance mix (Estimate) * % Medicare
% Medicaid
% Sliding Fee
% Private Insurance
% Self Pay
What is your practice type? *    Organization
Does your practice see Medicare patients?
Does your practice see Medicaid patients?
What is your specialty?    If other, please specify
Are you owned by a hospital or health system?     If yes, name of Hospital/Health System

Provider Information

 
Add a Provider
PrefixFirst Name *Last Name *Suffix Degree * 
 
Specialty *NPI *License # *State * Physician Champion 

EHR Project Plans

At the time of this application, where is your practice in the EHR implementation process? *

If other, please explain
If you have an EHR, please select the name and version.
If not in list, please specify
Do you have a high speed internet connection?
Do you have a budget for your EHR?
When did/do you plan to begin using your EHR?
Are you interested in exchanging health information through the N.C. Health Information Exchange?
Are you interested in Medicare and Medicaid EHR incentive programs?

Application Completed By

Your name *
Your title *
 
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